THE 



SCIENCE AND AET 



OF 



OBSTETRICS. 



S BY 

SHELDON LEAVITT, M. D. 

Professor of Obstetrics, Etc., in Hahnemann Medical College, and Clinical Professor 

of Midwifery in the Hahnemann Hospital of Chicago; Member of The 

American Institute of Homoeopathy; Author of "Therapeutics 

of Obstetrics," Etc., Etc., 



WITH AN INTRODUCTION 
\ 

BY 

PEOF. E. LUDLAM. 




CHICAGO: 
GEOSS & DELBEIDGE. 

1883. 



A 



,L 



Copyrighted 1882. 
By GROSS & DELBRIDGE; 

All rights reserved. 



JUNGBLUT, HENRICKS & CO., ELECTROTYPERS, CHICAGO. 

C. H. HANCHETT & CO., PRINTERS. * ANDERSON, HANSEN & CO., BINDERS. 

CHICAGO. CHICAGO. 



TO 



PROF. R. LUDLAM. 

In consideration of your high attainments as a gyn- 
aecologist and obstetrician; in acknowledgement of your many 
kindnesses; and as a token of high personal regard, 

THIS BOOK IS DEDICATED TO YOU. 

Whatever of merit it possesses is in great measure attrib- 
utable to you, inasmuch as it would never have appeared but 
for your wise advice and hearty encouragement. 

That the work as completed may receive your endorsement, 

is the fond hope of 

The Authok. 
Chicago, Oct. 20th, 1882. 



PREFACE. 

I have been prompted to prepare this work by a conviction of 
the existence of an urgent demand for a treatise on the Science 
and Art of Obstetrics, in our School of Medicine, which should 
embody the advances recently made, and set forth the distinctive 
characters of our therapeutics in a rational and practical manner. 

Treatment in obstetrical practice in a great measure is me- 
chanical, and does not involve the extensive application of thera- 
peutical resources. It is true that by the judicious use of 
homoeopathic remedies labor may often be divested of its patho- 
logical features; yet we must beware of expecting too much. 
We cannot reasonably hope to flex an extended foetal head, to 
amplify pelvic diameters, to reduce intra-uterine hydrocephalus, 
to effect version, or to arrest unavoidable hemorrhage by the 
most carefully affiliated remedy; and the sooner the sphere of 
remedial action can be settled, the better for us and the prin- 
ciples which we represent. The vantage-ground which we hold 
consists in our ability to reduce the number of cases demand- 
ing interference to a minimum, and to remove from the path- 
way of the parturient and puerperal woman all unnecessary diffi- 
culty and danger. 

In preparing a practical and reliable work of this kind, it is 
always found necessary to draw largely from the writing and 
experience of others. In doing so, I have endeavored to award 
due recognition, and have sought to appropriate only the most 
valuable and practical truths. 

(i.) 



11 

Though the matter has been prepared with the greatest care, 
important omissions and glaring errors will doubtless be dis- 
covered; on account of which, in advance, I implore the read- 
er's most gracious forbearance. 

To numerous friends I would return my hearty thanks for the 
many aids and encouragements afforded; and to my enterprising 
publishers, for their excellent and energetic performance of the 
mechanical part of the work. 

SHELDON LEAYITT, M. D. 
Chicago, Oct. 20th, 1889, 



CONTENTS. 



PART I. 

ANATOMY AND PHYSIOLOGY OF THE FEMALE GENERATIVE 

ORGANS. 

CHAPTER I. 

PAGB 

The Bones of the Pelvis . . . .25 

General form of the Pelvis. — The os Innominatum : — its outer surface, 
— its inner surface. — The os Ilium. — The os Ischium. — The os 
Pubis. — The Sacrum. — The Coccyx. 

CHAPTER II. 
The Pelvic Articulations ...... 32 

The Symphysis Pubis. — The Sacro-iliac Synchondroses. — Mechanical 
Relations of the Sacrum. — The Sacro- coccygeal Joint. — Abnormal 
Deviations. — The Pelvic Ligaments. — Movements of the Pelvic 
Articulations. — The Pelvis as a Whole. — Measurements of the Pel- 
vis. — Inclination of the Pelvis. — Horizontal Planes of the Pelvis. — 
Axis of the Parturient [Canal — The Inclined Planes.— Male and 
Female Pelvis. 

CHAPTER III. 
The Female External Generative Organs . . . .47 

Division According to Function and Situation — The Mons Veneris. — 
The Vulva.— The Clitoris.— The Labia Minora.— The Vestibule — 
The Vaginal Orifice. — The Hymen. — Carunculge Myrtiformes. — The 
Fossa Naviculars— The Secretory Apparatus.— The Vulvo-vaginal 
Glands.— The Bulbi Vestibuli.— The Vagina.— The Perineum. 

CHAPTER IV. 
The Female Internal Generative Organs . . . .61 

The Uterus. — The Uterine Ligaments. — The Uterine Cavity. — Structure 
of the Uterus : — the muscular structure — the mucous surface — the 
uterine glands — the uterine vessels — the uterine nerves — the lym- 
phatics. — Abnormalities of the Uterus. 

CHAPTER V. 
The Female Internal Generative Organs.— {Continued.) . . 73 

The Fallopian Tubes.— The Ovaries : the Graafian follicles!— the ovule. 
— vessels and nerves of the ovary. — The Intra-pelvic Muscles. — 
The Mammary Glands. 



(iii.) 



IV CONTENTS. 

PART II. 

PREGNANCY. 

CHAPTER I. 

Development of the Ovum . . . . . .83 

The Corpus Luteum of Menstruation. — The Corpus Luteum of Preg- 
nancy. — Migration of the Ovum. — Fecundation.— Course of Spermat- 
ozoa to Point of Fecundation. — Changes in the Ovum after Fecun- 
dation. — Sources of Nourishment. — The Chorion. — The Allantois. — 
The Decidua. — The Placenta: — general description — functions — 
changes preparatory to separation. — The Umbilical Cord. — The 
Liquor Amnii. 

CHAPTER II. 
Development of the Embryo and Foetus .... 101 
In the First Month.— Second Month.— Third Month.— Fourth Month- 
Fifth Month.— Sixth Month.— Seventh Month.— Eighth Month.— 
Ninth Month. — Circulation of Blood in the Foetus. — The Cranium. 
— The Sutures and Fontanelles. — Diameters of the Foetal Cranium. 
— Heads of Male and Female Children. — Attitude, Presentation and 
Position of the Foetus. — Presentations and their Causes. — Position. 
— Diagnosis of Presentations and Positions. — Examination per vagi- 
nam. — Diagnosis of Presentation and Position by Abdominal Pal- 
pation. — Diagnosis of Presentation and Position by Auscultation. — 
Diagnosis of Twin Pregnancy by Auscultation. — Diagnosis of Sex 
from Rapidity of Foetal Heart. 

CHAPTER III. 

Changes in the Mateenal Organism that are Wrought by Preg- 
nancy . . . . . . . . .125 

Uterine Changes : — in situation — inclination of its longitudinal axis — 
cervical position — size and texture of the cervix. — Vaginal and Vul- 
var Changes.— Changes in the Mammae.— Other Tissue Changes- 
Abdominal Changes. — Relation of the Uterus to Surrounding Parts. 
—Functional Disturbance of Neighboring Pelvic Organs. — Changes 
in the Blood. — Formation of Osteophytes. — Miscellaneous Changes. 
— The Permanent Changes. 

CHAPTER IV. 
The Diagnosis of Pregnancy .... .139 

Classification of the Signs.— Subjective and Objective Signs.— History of 
the Case. — The Menstrual Flow. — Pregnancy in Women who do not 
Menstruate. — " Morning Sickness." — Unreliability of Subjective 
Symptoms. — Menstruation During Pregnancy. — Objective Symp- 
toms. — Inspection. — Palpation : — cervical softening — fcetal move- 
ments — abdominal enlargement — ballottement. — Percussion. — Aus- 
cultation : — the fcetal heart — the uterine souffle. — Tabular Arrange- 
ment of the Signs of Pregnancy. — Differential Diagnosis. — Diagno- 
sis of Foetal Death. 

CHAPTER V. 
The Duration of Pregnancy . . . . . .151 

A Study of Comparative Physiology. — The Minimum. — The Maximum. 
— Prediction of Date of Confinement : — the date of quickening — the 
size of the uterus. 



CONTENTS. V 

CHAPTER VI. 
PSEUDOCYESIS ......... 159 

False, Spurious or Phantom Pregnancy— Conditions of Development — 
Etiology. — Symptoms. — Diagnosis. — Treatment. 

CHAPTER VII. 
The Pathology of Pregnancy . . . . . 164 

Extra-uterine Pregnancy ;— ovarian — tubo-ovarian— abdominal— inter- 
stitial— tubal.— Pregnancy in Rudimentary Cornu of a One-horned 
Uterus.— Rarer Varieties of Extra-Uterine Pregnancy.— Uterine 
Changes in Extra-Uterine Pregnancy.— Symptoms.— Terminations. 
— Diagnosis. — Treatment : — in cases of recent impregnation — puncture 
of the sac— injections into the sac— elytrotomy— use of electricity 
—laparotomy— cases of advanced gestation, the foetus still living— cases 
of gestation prolonged after death of foetus— gestation in bi-lobed ute- 
rus. — Missed Labor : — treatment. 

CHAPTER VIII. 
The Pathology of Pregnancy:— (Continued.) .... 182 
Premature Expulsion of the Ovum. — Predisposing Causes : — atrophy of 
uterine mucous membrane — hypertrophy of uterine mucous mem- 
brane. — Proximate Causes : — hyperaemia of the uterus. — Symptoms : 
early abortions — later abortions. — Incomplete Abortion : — diagnosis 
of incomplete abortion — membranes expelled, foetus retained — ex- 
pulsion of one foetus in twin pregnancy. — Diagnosis of Abortion. — 
Prognosis.— Treatment: — preventive treatment— promotive treatment : — 
the tampon — emptying the uterus — how to remove the secundines 
— antiseptic precautions — neglected cases. 

CHAPTER IX. 

Pathology of the Decidita and Ovum ..... 208 
Endometritis. — Pathology of the Chorion : — hydatidiform degeneration — 
causes — symptoms and course — diagnosis— treatment. — Pathology of 
the Placenta : — form — size — situation— degenerations and new forma- 
tions — other morbid states — syphilis of the placenta— apoplexy and 
inflammation. — Pathology of the Amnion : — hydramnios — etiology- 
signs and symptoms — diagnosis — prognosis — effect on labor — treat- 
ment — deficiency of amniotic fluid — anomalies of appearance of the 
liquor amnii. — Pathology of the Cord : — knots — torsion — coiling — 
cysts — hernia — calcareous deposits — stenosis of vessels — anomalies 
of insertion. — Pathology of the Foetus : — inflammations — blood dis- 
eases transmitted through the mother — syphilis — measles and scar- 
latina — malaria and lead poisoning — dropsies — effects of violence — 
intra-uterine amputations — monstrosities — death and retention — 
mummification — maceration.— Moles : — the mole of abortion — the 
fleshy mole. 

CHAPTER X. 
Diseases and Accidents of Pregnancy .... 234 

Hygiene of Pregnancy.— Derangements of the Digestive System : — prog- 
nosis — treatment — change of habitation, air and scenery — local uter- 
ine treatment — medicinal treatment — the production of abortion — 
minor gastric disorders.—Pruritus.— Face-ache.— Cephalalgia.— Insom- 
nia. — Anaemia: — treatment. — A lbuminuria : — causes — effects — prog- 
nosis — symptoms — treatment — advisability of induced labor. — Cho- 
rea. — Hysteria. — Paralysis. — Syncope. — Painful Breasts. — Pain in 



VI CONTENTS. 

the Side. — Pain in the Abdomen. — Leucorrhoea. — Odontalgia. — 
Cramps. — Inj uries. 

CHAPTER XI. 
Diseases and accidents of Pregnancy. — (Continued.) . . 255 

Constipation. — Diarrhoea. — Vesical Irritation. — Cough. — Dyspnoea. — 
Hemorrhoids. — Anteversion and Anteflexion of the Uterus. — Retro- 
version and Retroflexion of the Uterus.— Prolapse of the Uterus- 
Hernia of the Gravid Uterus. — Surgical Operations in Pregnancy. — 
Cardiac Diseases. — Eruptive Fevers : — variola — scarlatina. — Contin- 
ued Fevers. — Malarial Fevers. — Pneumonia. — Phthisis. — Syphilis. 



PART III. 

LA BOB. 
CHAPTER I. 

Causes of Labor r . ...... 273 

The Expelling Powers. — The Uterine Contractions. — Influence of the 
Pains of Labor on the Organism. — Contractions of the Uterine Liga- 
ments. — The Vaginal Contractions. — Abdominal Aid. — The Pains of 
Labor. 

CHAPTER II. 
Clinical Course of Labor, and Its Phenomena . . . 283 

The Stages of Labor. — False Labor-pains. — The First Stage. — The Mech- 
anism of Dilatation. — The Second Stage.— The Third Stage. — Dura- 
tion of Labor. — The Hour of Labor. — Influence of the Tide on Par- 
turition. 

CHAPTER III. 
The Management of Normal Labor ..... 298 
Preliminary Arrangements. — Response to Calls. — Armamentarium. — 
How to Approach the Patient. — The Examination. — Has Labor 
Begun? — False Labor-pains. — Patient's Bed and Dress. — Position of 
the Patient. — The Physician's Attendance During the First Stage. — 
Bearing Down. — Treatment of the Membranes. — The Second Stage. 
— The Use of Anaesthetics. —Indications for Interference, — Emptying 
the Bladder. — Incarceration of the Anterior Uterine Lip. — Support 
of the Perineum. — Episiotomy. — Frequency of Perineal Rupture. — 
Varieties of Rupture. — Delivery of the Shoulders. — Treatment ot 
the Cord:— early and late ligation.— The Third Stage.— Credo's 
Method of Placental Delivery. — The Combined Method.— Manual 
Compression of the Uterus. — Post-partum Care of the Woman. — 
The Binder. — Therapeutics. 

CHAPTER IV. 
Use of Anesthetics in Midwifery Practice .... 325 
In Cases of Normal Labor.— In Operative Midwifery.— Rules for Admin- 
istering. 

CHAPTER V. 
The Mechanism of Labor . . . . , . .331 

Various Positions of the Foetus. — Thecry of Classification. — Basis ot 
Classification. — Relative Frequency of Positions. — Points of Coinci- 



CONTENTS. YU 

cidence Between the Various Positions : — vertex presentation — face 
presentation — breech presentation. 

CHAPTER VI. 
The Mechanism of Labor. — {Continued.) . . . .340 

Vertex Presentation. — Relative Frequency of Vertex Presentations. — 
Relative Frequency of First Position.— Condition at the Beginning 
of Labor. — Mechanism of the First Position :— descent and flexion — 
direct descent — passage through the pelvis — rotation — passage 
through the outlet— restitution— expulsion of the trunk.— Mechanism 
of the Second Position. — Mechanism of Occipito-posterior Positions: 
— hign rotation — conversion into occipitoanterior positions. — Caput 
Succedaneum. — Configuration of the Head in Vertex Presentation. 

CHAPTER VII. 
The Mechanism of Laboe. — (Continued.) .... .354 

Face Presentation. — Character of Labor. — Causes of Face Presentation. — 
Relative Frequency of Positions.— Mechanism of the First Position, 
—descent and extension — rotation — flexion. — Form of the Cra- 
nium in Face Presentation. — Prognosis. — The Second Position. — 
Third and Fourth Positions. — Treatment : — conversion into vertex 
presentation — when the face does not engage the brim — persistent 
mento-posterior positions. — Brow Presentation. 

CHAPTER VIII. 
The Mechanism of Labor. — (Continued.) .... .365 

Pelvic Presentation. — Frequency. — Prognosis. — Causes of Infantile Mor- 
tality. — Etiology. — Mechanism of First and Second Positions of the 
Breech : — descent — rotation — expulsion. — Mechanism of the Third 
and Fourth Positions. — Footling Presentation. — Treatment of the 
Arms in Head-last Cases. — Breathing Space for the Foetus when the 
Head is Retained. — Forceps to the After-coming Head. — Form of the 
Head in Pelvic Presentation. — Management of Pelvic Presentation. 
— Question of Cephalic Version. — Expulsion of the Trunk. — Extrac- 
tion of the Head. 

CHAPTER IX. 
The Mechanism of Labor. — (Continued.) . . . .374 

Transverse Presentation. — Frequency. — Various Positions. — Causes. — 
Diagnosis. — Prognosis. —Spontaneous Evolution. — Spontaneous Ex- 
pulsion. — Treatment : — favorable moment for operating — preserva- 
tion of the membranes — version. — Death of the Foetus.- — Unaided 
Termination. — Complex Presentations: — hand with the head — feet 
and hands — head, hand and foot. 

CHAPTER X. 

Labor Rendered Difficult or Dangerous by Anomalies of the 

Expellent Forces ....... 387 

Precipitate Labor. — Uterine Inertia or Weak Labor : — causes— symptoms 
— treatment : — therapeutics — use of forceps in — third stage of labor 
complicated by inertia. 

CHAPTER XL 
Labor Obstructed by Maternal Soft Parts .... 395 
Rigidity of the Cervix Uteri : — symptoms — treatment : — use of dilators — 
manual dilatation — incision — use of the forceps — craniotomy — ther- 



Vlll CONTENTS. 

apeutics. — Uterine Tetanoid Constriction : — character of the stricture 
— diagnosis — treatment. — Agglutination of the External Uterine 
Orifice. — Complete Obliteration of the Cervical Canal. — Tumefaction 
and Incarceration of the Anterior Lip. — Carcinoma of the Cervix. — 
Cauliflower Tumors of the Cervix.— Thrombus of the Vulva and 
Yagina. — Cj'stocele. — Impaction of Fceces in the Eectum. — Recto- 
cele. — Vesical Calculus. — Diffuse Swelling. — Unyielding Hymen. — 
Uterine Polypi. — Tumors of the Ovary. — Eigid Perineum. — u Rotten" 
Perineum. — treatment : — immediate perineorrhaphy. 

CHAPTEE XII. 

Labor Obstructed by Some Unusual Condition of the Mater- 
nal Osseous Structures ...... 412 

Large Pelvis. — Symmetrically Contracted Pelvis. — Flattened Pelvis. — 
Flattened, Generally Contracted, Pelvis. — Irregular Rachitic and 
Malacosteon Pelvis. — Obliquely-Contracted Pelvis. — Flattening of 
the Sacrum. — Exaggerated Curve of the Sacrum- Funnel-shaped 
Pelvis. — Infantile Type of Pelvis.— Deformities from Spinal Curva- 
ture. — Eobert's Anchylosed and Transversely Contracted Pelvis. — 
Spondylolisthetic Pelvis. — Osteo-sarcoma and Exostosis. — Other 
Osseous Tumors and Prominences. — Absence of the Symphysis. — 
The Chief Causes of Pelvic Deformity.— Pelvimetry .—Influence of 
Pelvic Contraction on the Uterus During Pregnancy. — Influence of 
Pelvic Contraction on Presentation. — Influence of Pelvic Contrac- 
tion on Labor-pains. — Influence of Pelvic Contraction on the First 
Stage of Labor. — Effect of Pressure on the Soft Tissues. — Effect of 
Pressure on the Child's Head. — Prognosis of Pelvic Deformity. — In- 
duction of Abortion in Extreme Deformity. — Induction of Prema- 
ture Labor. — When to Interfere. — Cases Wherein Delivery of a Liv- 
ing Child is Possible. — Cases Wherein a Living Cnild Cannot be 
Born. — Cases Wherein Extraction Through the Natural Passages is 
Impossible. 

CHAPTER XIII. 

Labor Rendered Difficult or Dangerous by Some Unusual Con- 
dition of the Foztus or its Appendages .... 433 
Plural Pregnancy : — arrangement of the membranes — conditions attend- 
ing development — management of first birth — delay after birth of 
first child — locked twins — double monsters. — Intra-Uterine Hydro- 
cepalus: — diagnosis — head-last cases — treatment. — Hydrothorax. — 
Ascites and Vesical Distension. — Other Abnormalities : — cranial de- 
formities — large foetuses — dorsal displacement of the arm. 

CHAPTER XIV. 

Labor Rendered Difficult or Dangerous by Some Unusual Con- 
dition of the Foetus or its Appendages — {Continued.) . . 447 
Placenta Praevia: — varieties — frequency — causes of the hemorrhage — 
symptoms — diagnosis — prognosis — treatment /—the question of favor- 
ing fcetal expulsion — modes of promoting labor — evacuation of the 
liquor amnii — the vaginal tampon — complete separation of the pla- 
centa — partial separation — treatment when the os is either dilated 
or dilatable. — Prolapse of the Funis : — frequency — prognosis — causes 
— signs — has pulsation ceased — preventive treatment — postural 
treatment — artificial reposition — treatment when reposition fails. — 
Accidental Hemorrhage : — its character — causes — varieties — symp- 
toms of external hemorrhage — symptoms of internal hemorrhage — 
treatment. 



CONTENTS. IX 

CHAPTER XV. 

Othee Difficulties and Dangees Aeising in the Fiest and Sec- 
ond Stages of Laboe ...:... 477 
Rupture of the Uterus: — seat and character — etiology — symptoms — 
proguosis — treatment: — comparative results of various methods. — 
Laceration of the Cervix. — Laceration of the Vagina. — Laceration 
of the Vestibule. 

CHAPTER XVI. 
Difficulties and Daxgees Aeising in the Thied Stage of Laboe. 484 
Post-par turn Hemorrhage. — Causes. — Premonitory Symptoms.— General 
Symptoms. — Secondary Hemorrhage.— Prognosis. — Treatment : — 
hemorrhage of the first degree — hemorrhage of the second degree — 
hemorrhage of the third degree — treatment of concealed hemorrhage 
— secondary hemorrhage — therapeutics. 

'.CHAPTER XVII. 

Difficulties and Dangees Aeising in the thied Stage of Laboe. 

— (Continued.) . ....... 501 

Retained Placenta, — Acute Inversion of the Uterus : — causes — symptoms 
— diagnosis — treatment.— Asphyxia Neonatorum : — morbid anatomy 
— diagnosis and prognosis — treatment : — Sylvester's method of artifi- 
cial respiration — Marshall Hall's — Schroeder's — Schultze's — How- 
ard's. 

CHAPTER XVIII. 
Obsteteic Opeeations ....... 511 

Induction of Premature Labor : — rupture of the membranes — dilatation 
ofjthe cervix — intra-uterine injections — catheterization of the uterus 
— Kiwisch's douche — introduction of foreign bodies into the vagina. 
— Induction of Abortion. 

CHAPTER XIX. 
Tuening . ........ 514 

Conditions Calling for the Operation. — Favorable Conditions. — Cephalic 
Version. — Podalic Version. — Combined Method. — The Internal 
Method. 

CHAPTER XX. 
The Foeceps ......... 525 

History. — The Short Forceps.— The Long Forceps. — Designations of the 
Blades. — Action of the Forceps. — Modes of Application : — the pelvic 
— the cephalic. — Conditions calling for the Forceps. — The Prelimi- 
naries. — The Application. — Traction. — Removal. — Forceps in Occip- 
i to-posterior Positions. — Forceps in Face Presentation. — Forceps in 
Breech Presentation. — Forceps to the After-coming Head. 

CHAPTER XXI. 
Minoe Obsteteic Insteuments And Opeeations . . .541 

The Vectis. — The Blunt Hook. — Hypodermic Injections. — Catheterism. 
— Transfusion of Blood : — the immediate method — chemical preven- 
tion of coagulation— defibrination of the blood. — Transfusion of 
Milk. 



X CONTENTS. 

CHAPTER XXII. 
Operations Involving Desteuctiox of the Fcetus . . .549 

Craniotomy: — its sphere— frequency of employment — instruments em- 
ployed : — the perforator — the crotchet — craniotomy forceps — the cra- 
nioclast — the cephalotribe — comparative merits of cephalotripsy and 
cranioclasm — comparative merits of craniotomy and Csesarean sec- 
tion.' — Embryotomy : — decapitation — extraction of the body andsub- 
quent delivery of the head — evisceration. 

CHAPTER XXIII. 

Cesarean Section — Pokro's Operation — Laparo-Elytrotomy — 

Symphysotomy . . ..... 558 

Caesarean Section on the Living Woman. — Causes of Death after the Op- 
eration. — American and English Statistics. — The Operation.— Gen- 
eral Considerations. — Preliminaries. — Examinations. — Form of the 
Uterus. — Advisability of Operating Early. — The Incisions. — Extrac- 
tion of the Child. — Closure of the Wounds. — After-care of the Pa- 
tient. — Post-mortem Csesarean Section. — Porro ? s Operation. — Laparo- 
elytrotomy. — Symphysotomy. 



PART IV. 

THE PUERPERAL STATE. 
CHAPTER I. 

Phenomena and Management of the Puerperal State . . 572 

Mortality of Childbirth. — Phenomena Succeeding Delivery. — Postpar- 
tum Blood Changes. — Pulse Changes.— Moisture of the Skin. — Tem- 
perature. — Uterine Involution. — The Excretions — Changes in Uter- 
ine Mucous Membrane. — Vaginal Changes. — The Lochia. — The Lac- 
teal Secretion : — therapeutics. — Means for Arresting the Lacteal Se- 
cretion.— After-pains. — Necessary Attentions to Puerperal Women. 
— The Physician's Visits. — Regimen. — The Bowels. — Time for Get- 
ting Up. — Care of the Child. 

CHAPTER II. 

The Puerperal Diseases . . . . . . .589 

Phlegmasia Dolens : — symptoms — etiology — pathology — treatment. — Pu- 
erperal Mania. — Puerperal Insanity. — Insanity of Lactation. 

CHAPTER III. 
The Puerperal Diseases. — {Continued.) .... .599 

Causes of Sudden Death During Labor and the Puerperal State : — pul- 
monary thrombosis and embolism- — syncope — death from entrance 
of air into the veins. — Defective Lacteal Secretion. — Depressed Nip- 
ples. — Excessive Lacteal Secretion. — Sore Nipples. — Mastitis Puer- 
peralis : — structures involved — symptoms — causes — treatment. 

CHAPTER IV. 
The Puerperal Diseases.— {Continued.) .... .610 

Puerperal Eclampsia. — Etiology and Pathology. — Symptoms. — Diagno- 
sis. — Prognosis. — Treatment : — preventive— curative — therapeutical 
resources. 



CONTENTS. XI 

CHAPTEE V. 
The Puerperal Diseases.— {Co ntinued.) . . . . .617 

Puerperal Fever. — (Puerperal Septicaemia, Sapraeniia, Pyaemia.) — 
Pathological Anatomy. — Autogenitic Sepsis. — Heterogenetic Sepsis : 
cadaveric poisoning — erysipelas — scarlatina — infection from other 
puerperal women. — Manner of Conveying the Contagium. — Symp- 
toms : — endometritis and endocolpitis — parametritis, perimetri- 
tis and general peritonitis — septicaemia, lymphatica and venosa — 
pure septicaemia, — Preventive Treatment, — Curative Treatment. — 
Palliative Treatment. — Regimen. — Use of Antiseptic Injections. — 
Eelief of Tympanites.— General Therapeutics. 



LIST OF ILLUSTRATIONS. 



FIGUBE, PAGE 

1. The right os innominatum,— outer surface, ... 26 

2. The right os innominatum,— inner surface, - 27 

3. The anterior surface of the sacrum, 31 

4. Section of the symphysis pubis, 32 

5. Section through the left sacro-iliac articulation, - 33 

6. Diagram showing the oscillatory movement of the sacrum, - 38 

7. The articulated pelvis, -38 

8. Showing the diameters of the superior strait, - 39 

9. Showing the diameters of the outlet, 40 

10. Planes and axis of the pelvis, 42 

11. Pelvic angles, 43 

12. Numerous horizontal pelvic planes, and pelvic axis, 44 

13. Axis of the entire parturient canal, 44 

14. Section of pelvis,— inner surface, 45 

15. Male pelvis, 45 

16. Pemale pelvis, -- 

17. Lateral view of the erectile structures of the external generative 

organs, 48 

18. The external female generative organs, 49 

19. Pigure showing the hymen, 51 

20. Pigure showing the hymen, 51 

21. Vascular supply of vulva, - 53 

22. The vagina (after removal of posterior wall.) 54 

23. Section of female pelvis, 56 

24. Muscles of the perineum, 58 

25. The external and internal generative organs, - 60 

26. Anterior view of virgin uterus, 62 

27. Sections of virgin uterus, 64 

28. Muscular fibres of unimpregnated uterus, 65 

29. Developed muscular fibres from the gravid uterus, - 66 

30. Section of uterine mucous membrane, with glands, 67 

31. Arterial vessels in uterus ten days after delivery, - 6S 

32. Nerves of the uterus, 69 

33. Uterus with double cavity, and slight deviation of form, - 70 

(xiii.) 



XIV LIST OF ILLUSTRATIONS. 

34. Uterus septus bilocularis, - -71 

35. Double uterus and vagina, 72 

36. Ovary and Fallopian tube, 73 

37. Longitudinal section of an ovary, 75 

38. Portion of vertical section through ovary of bitch, 76 

39. Section of Graafian follicle, 77 

40. Uterine and utero-ovarian veins, 78 

41. Section of pelvis showing the pyramidal muscles, - 79 

42. Mammary gland, -- 81 

43. Spermatozoa, ■ -.■-.- 87 

44. Bifurcation of tubal canal, 89 

45. Stage of segmentation of the yolk, 90 

46. Stage of segmentation of the yolk, 90 

47. Stage of segmentation of the yolk, 90 

48. External surface of ovum, showing area germinativa, 91 

49. Stage of embryonic development, - 92 

50. Stage of embryonic development, 92 

51. Human embryo at the third week, with chorionic villi, 93 

52. Formation of the decidua reflexa, first stage, 95 

53. Formation of the decidua reflexa, completed, - 95 

54. Flap of decidua reflexa turned down, disclosing the ovum, - 96 

55. Placental villus, magnified, 97 

56. Foetal surface of the placenta, 98 

57. Uterine surface of the placenta, 99 

58. Section of uterus and placenta in the fifth month, ... loo 

59. Ovum and embryo, 102 

60. Ovum at five months, - 103 

61. Diagram of the foetal circulation, - ' - - - - - 106 

62. The vertex, 109 

63. Posterior view of the cranium, 109 

64. Lateral view of foetal head, 110 

65. Attitude of foetus in utero, - Ill 

66. Situation and surroundings of the foetus, 114 

67. Figure illustrating abdominal palpation, - 117 

68. Figure illustrating abdominal palpation, 117 

69. Figure illustrating abdominal palpation, - 118 

70. Figure showing the locations of the foetal heart-sounds, - - 119 

71. Location of heart-sounds in first position of the vertex, - 120 

72. Location of heart-sounds in first position of the face, - - 120 

73. Location of heart-sounds in first position of breech, - - 120 

74. Location of heart-sounds in dorso-anterior position of trans- 

verse presentation, 120 

75. Location of heart-sounds in twin pregnancy, - - - - 120 

76. Cervix uteri at the end of third month, 128 

77. Cervix uteri at the beginning of fifth month, - - - - 128 

78. Bulging of anterior uterine wall from pressure of foetal head, 129 

79. Cervix uteri at the end of eighth month, - r .- - - 130 

80. Cervix of a woman who died in the eighth month, - 130 

81. Cervix uteri beyond the seventh month, 131 



LIST OF ILLUSTRATIONS. XV 

S2. Appearance of the areola in pregnancy, 133 

83. Lateral view of the enlarged abdomen at the sixth month, - 134 

84. Lateral view of the enlarged abdomen at the ninth month, - 134 

85. Size of the uterus at various stages of pregnancy, - - - 158 

86. Abdominal pregnancy, 166 

87. A lithopsedion, - 167 

88. Interstitial pregnancy, - - 167 

89. Tubal pregnancy, ---------- 169 

90. Tubal pregnancy, - 170 

91. Pregnancy in a rudimentary cornu, 171 

92. Ovum with imperfectly developed decidua, - 184 

93. Uterus with basis of a fibrinous polypus after an abortion, - 190 

94. The ovum forceps, --------- 199 

95. Sieman's intra-uterine curette, ------- 202 

96. Sim's intra-uterine curette, ------- 202 

97. Vertical section of pelvis, showing uterus drawn down with 

the volsella, ---------- 204 

98. Loomis' placenta forceps, -- 205 

99. Schnetter's placenta forceps, ------- 205 

100. Small hook and lever, --------- 206 

101. Hypertrophied decidua laid open, _-_---, 209 

102. Hydatidiform mole, - - - - 213 

103. Hydatidiform mole, placental origin, ----- 213 

104. Fatty degeneration of the placenta, 219 

106. Knot of the umbilical cord, 225 

107. Knot of the umbilical cord, 225 

108. Hernia of the cord, --------- 227 

109. Intra-uterine amputation, --------230 

110. Eelative size and inclination of the uterus at the close of gesta- 

tion, ------------ 258 

111. Ketroflexion of the gravid uterus, ------ 259 

112. Soft rubber catheter, --------- 261 

113. The uterine mucous membrane, - - - - - - 275 

114. Section of uterus, showing foetus in membranes, - 285 

115. Section of a frozen body at the close of the first stage, - - 287 

116. The parturient canal, - 288 

117. The uterus and parturient canal, foetus removed, - - - 291 

118. Distension of the perineum, - 293 

119. Normal mode of separation and expulsion of the placenta, 295 

120. Mode of separation and expulsion of the placenta when traction 

is made on the cord, --------- 295 

121. The vaginal touch, - - - - 302 

122. Method of perineal support, - 313 

123. Ligatures of the umbilical cord, ------- 318 

124. The square knot, --------- 31s 

125. Crede's method of placental delivery, ------ 321 

126. Inversion of placenta from traction on the cord, - 822 

127. Allis' ether inhaler, --------- 331 

128. Chisholm's ether inhaler, -------- 331 



XVI LIST OF ILLUSTRATIONS. 

129. First position of the vertex, - - 334 

130. Second position of the vertex, - - - - - - - 334 

131. Third position of the vertex, - - - - - . - - - 334 

132. Fourth position of the vertex, - - 334 

133. First position of the breech, 335 

134. Second position of the breech, - 335 

135. Third position of the breech, --------335 

136. Fourth position of the breech, ------- 335 

137. Fourth position of the feet, -------- 336 

138. Third position of transverse presentation, - 336 

139. Second position of transverse presentation, - 337 

140. First position of the vertex, 338 

141. First position of the breech, --------338 

142. Second position of the vertex, ------- 339 

143. Second position of the breech, - 339 

144. First position of the vertex, - 343 

145. Lateral obliquity of the head in the pelvic cavity, first position, 345 

146. Leverage action of the foetal head, 346 

147. Head approaching the outlet in the first position, - - - 347 

148. The mechanism of labor in the first position, - 347 

149. Second position of the vertex, 348 

150. Third position of the vertex, ------- 349 

151. Fourth positiomof the vertex, - - - - ■ - - - 349 

152. Third position of the vertex seen from above, - - - 350 

153. Occipito-posterior termination of the third position of the ver- 

tex, - 351 

154. Outline of foetal head at birth, 354 

155. Outline of foetal head four days after birth, - - - - 354 

156. Form of the head in vertex presentation, 355 

157. Face presentation at the outlet, mento-posterior position, - 356 

158. Engagement of the head in face presentation, - 358 

159. Mechanism of face presentation, first position, - 359 

160. Mento-anterior termination of face presentation, ~ - - 361 

161. Diagram illustrating Schatz's method of converting face into 

vertex presentations, --------- 363 

162. Diagram illustrating Schatz's .method of converting face into 

vertex presentations,. _--___--- 363 

163. Diagram illustrating Schatz's method of converting face into 

vertex presentations, -_-_._--- 363 

164. Mento-posterior termination of labor, 364 

165. Outline of head, brow presentation, 365 

166. First position of the breech, ------- 368 

167. Expulsion of the trunk in breech presentation, - - - - 369 

168. Birth of the shoulders in breech presentation, - 370 

169. Third position of the breech, - 371 

170. Completion of rotation and extraction of the head, - - 372 

171. Footling presentation, 373 

172. Shape of the head in pelvic presentation, - 374 

173. Ventral presentation, 376 



LIST OF ILLUSTEATIONS. XV11 

174. Section of uterus showing foetus in transverse presentation 

within the membranes, 377 

175. Dorso-anterior position of transverse presentation, - - 378 

176. Dorso-posterior position of transverse presentation, - - - 379 

177. Arm presentation, 380 

178. Spontaneous expulsion, from a frozen specimen, - - - 381 

179. Spontaneous expulsion, first stage, - 382 

180. Spontaneous expulsion, second stage, ------ 383 

181. Eunning noose on the foot, - 387 

182. Complex presentation, - - - - 387 

183. Cystocele obstructing labor, 404 

184. Small cervical polypi, 407 

185. Labor impeded by a uterine polypus, 408 

186. Labor impeded by ovarian tumor, ------ 409 

187. The flattened pelvis, 414 

188. Malacosteon pelvis, 415 

189. Isabel Kedman's pelvis, 416 

190. Obliquely distorted pelvis, 417 

191. Flattening of the sacrum, .__ 418 

192. Exaggerated sacral curve, -------- 418 

193. Eobert's pelvis, - - 419 

194. Spondylolisthetic pelvis, 419 

195. Pelvic exostosis, -« 419 

196. Greenhalgh's pelvimeter, - - ' - 423 

197. Manual pelvimetry, 424 

198. Change of cephalic form, from molding in difficult head-last 

cases, --. 430 

199. Change of cephalic form, from molding in difficult head-last 

cases, - 430 

200. Transverse diameters of the head, as viewed from above, - - 431 

201. Molding of the head at the brim, 432 

202. Twins in utero, 436 

203. Head-locking, 438 

204. Head-locking, - - - - - - 439 

205. Double monster united laterally, ------ 440 

206. Double monster united anteriorly, - ' 441 

207. Hydrocephalic head at the brim, - - - -' 443 

208. Hydrocephalic head, front view, 444 

209. Mode of perforating the head in pelvic presentations, 445 

210. Acrania, front view, - - - - - • - - -- 446 

211. Acrania, lateral view, -._ 446 

212. Dorsal displacement of the arm, -------447 

213. Varieties of placental implantation, ----- 449 

214. Central placenta prsevia, - 453 

215. Prolapse of the funis, - 466 

216. Inclination of the uterus in dorsal posture, - - - - - 469 

217. Postural treatment for prolapse of the funis, - - - - 470 

218. Irregular uterine contraction with retention of the placenta, - 502 

219. Incipient inversion of the uterus, 504 



XV111 LIST OF ILLUSTRATIONS. 

220. Commencement of inversion of the cervix uteri, - - - 504 

221. Version by conjoint manipulation, first stage, - 518 

222. Version by conjoint manipulation, second stage, - 519 

223. Version by conjoint manipulation, third stage, - 520 

224. Version in head presentation, 522 

225. Version in transverse presentation, 523 

226. Use of running noose on the foot, ----- - - 523 

227. Turning by the noose, 524 

228. Chamberlen's forceps, 525 

229. Davis' forceps, - 526 

230. Comstock's forceps, ----------527 

231. Budd's forceps, - - - 527 

232. Simpson's forceps, 527 

233. Elliot's forceps, "-• 528 

234. Hodge's forceps, - - - 528 

235. Hale's forceps, 528 

236. Vedder's forceps, - - - -529 

237. Leavitt's forceps, 529 

238. Tarnier's forceps, 530 

239. Forceps at the brim, pelvic mode, 531 

240. Forceps in the cavity, cephalic mode, 532 

241. Introduction of the first blade, 535 

242. Showing how the head is usually seized in the cephalic mode of 

application, ---- 536 

243. Folding vectis, - - - - - - 541 

244. Ryerson's vectis, _-__ 542 

245. Taylor's blunt hook, 543 

246. Soft rubber catheter, 544 

247. Manner of holding the catheter, 544 

248. Fryer's instrument for immediate transfusion, - 546 

249. Allen's transfuser, 547 

250. The " skin cup," 548 

251. Thomas' perforator, 550 

252. Blot's perforator, 551 

253. Blunt hook and crotchet, - 551 

254. Thomas' craniotomy forceps, - 551 

255. Use of the craniotomy forceps, - - - - - - - 552 

256. Simpson's cranioclast, 553 

257. Lusk's cephalotribe, 554 

258. Foetal head crushed by the cephalotribe, 554 

259. Decapitating hook, 556 

260. Mode of using the decapitating hook, 557 

261. The Csesarean operation, 560 

262. The clinical thermometer, 575 

263. Pulse and temperature diagram, 576 



INTRODUCTION. 

Dear Doctor: — 

If one physician more than another has an especial interest 
in the publication of new and practical works on Obstetrics, it 
is the busy gynaecologist, whose daily and almost hourly duty it 
is to remedy the consequences of ignorant and meddlesome mid- 
wifery. On this point alone, if there were no other, I am ready 
to congratulate you on the timely issue of your excellent treatise. 
Through the more thorough education of the profession in this 
important branch, it will be an honor to the school from which 
it comes, and also to our literature. Based upon your experience 
in the obstetric clinic of our hospital, and in private practice; 
adapted to the real needs of the pupil and the practitioner; 
abounding in resources that are designed to anticipate and to 
avert the risks of gestation and of parturition, your book is cer- 
tainly destined to be useful even beyond the scope that you have 
marked out for it. 

As an old teacher of midwifery, who is proud to have had the 
training of so many excellent obstetricians, yourself included, I 
am particularly pleased with the clearness and the fullness with 
which you have given the obstetric anatomy of the pelvis and of 
the foetal head, and with your treatment of the mechanism of 
labor. These subjects are indispensable, and are more certain 
to be thoroughly mastered if they are well presented by the 
lecturer and the author. It should be indictable at the common 
law for any one to pretend to the function of an accoucheur who 

(xix.) 



XX INTRODUCTION. 

is ignorant of the mechanism of labor, whether normal or ab- 
normal. 

In your especial chapter upon the different presentations and 
positions, the method of comparison and the means of illustra- 
tion that you have employed, have put a very difficult subject in 
a clear and practical light. I know of no author in any language 
who is so free from confusing his readers in this regard. This 
kind of instruction is the small coin that the practitioner will 
need, and must carry with him to the parturient chamber. If in 
these matters "all mystery is defect," and I believe it is, you 
certainly deserve credit for your remarkable plainness and per- 
spicuity. 

In the light of recent and promising developments in the phys- 
iology and pathology of pregnancy, as they are related to 
obstetrics and gynaecology, your discussion of this department 
of your general subject has an added interest. Conception, 
nidation, the formation of the decidua and of the placenta, the 
growth of the embryo and then of the foetus, and the local and 
general changes in the maternal organism consequent upon ges- 
tation, are carefully considered, and thoroughly illustrated by 
the cuts that accompany the text. 

The chapter on the attitude, presentation and position of the 
foetus, with their diagnosis, is a fitting and excellent prelude to 
the study of labor and its management. These pages abound in 
the evidence of clinical drill and demonstration, and of a careful 
study of the whole subject, with an ultimate desire to preserve 
the result in a ready and available form. They embody the 
teachings of the best obstetricians without the sacrifice of your 
own individuality. The innovations are modest and suggestive, 
and they will doubtless prove acceptable. 

I am glad that in the treatment of the haemorrhages incident 
to delivery you have taken such pains as the subject really de- 
mands. For it has seemed to me to be very wrong, not to say 



INTRODUCTION. XXI 

criminal, to pass over this fearful contingency so lightly as is the 
custom with some of our modern authors. Post-partum haemor- 
rhages are always bad enough, but in their unavoidable and 
accidental forms they deserve all the consideration that you 
have given them. Our students and practitioners should be 
forewarned and forearmed against them. Your text is in evi- 
dence that my earnest preaching upon this subject in former 
years has not been in vain; and it will awaken the right kind of 
an echo among our responsible workers everywhere. 

In operative midwifery, especially your treatment of the use 
and application of the forceps, the indications and contra- 
indications, the mechanism and modus operandi of these instru- 
ments, are very carefully and practically considered. The fact 
that the forceps have been abused, and that in the hands of the 
ignorant they have wrought a great deal of mischief, is no argu- 
ment against their intelligent and skillful employment. And the 
fact that you have so often and so successfully applied them 
upon the living subject for the benefit of our college classes has 
enabled you to put the matter all the more clearly, in these 
pages. For it is sometimes an immense advantage for an author 
to have rehearsed his part to a crowd of competent and interest- 
ed witnesses, before committing himself to the printed page, 
and your readers will get the benefit of this drill on your part. 
If your directions are carefully and intelligently followed there 
will be little danger of harm from the resort to this very use- 
ful and indispensable instrument. 

Version in your hands, with the aid of external manipulation, 
is an excellent and available obstetric resource. The conditions 
that require it in one or another of its forms, and the directions 
given for its performance are clearly stated and practically set 
forth. Your excellent illustrations of this process of voluntary 
evolution furnish one of the most attractive and useful features 
of the book. The aid to turning by the proper postural treat- 



XX11 INTBODUCTION. 

ment, and the relative importance of version by the vertex, when 
it is practicable, are properly emphasized. These obstetric ma- 
nipulations deserve a plain description, and a thorough illumina. 
tion, so that, in an emergency, the physician who is forced to 
make them may have good counsel at hand in an author who 
has not buried his meaning under a heap of word-rubbish. You 
have succeeded in giving the most explicit and available direc- 
tions possible for this and other forms of manual midwifery. 

I have looked over your fresh, uncut pages for the little items 
which tell whether one has written from experience, and with a 
view to assist his readers, or merely with the idea of making a 
book. And I have been pleased to find that you have given the 
most careful instruction as to the introduction of the catheter, 
the resuscitation of the asphyxiated infant, and kindred subjects. 
I also find a painstaking description of pseudocyesis, and a care- 
ful differentiation of true from false labor pains. These minor 
matters answer for your fidelity, and will be extremely useful. 

My own idea is that, in these latter days, the consideration of 
the puerperal state should be taken from our works on obstet- 
rics and gynaecology, and devoted to separate treatises. The 
subject is too large and too important, and, both on account of 
its immediate clinical history, and of its far-reaching conse- 
quences upon the health of women, merits a more careful and 
thorough consideration than most teachers and writers on these 
topics can afford to give it. For this reason I would have pre- 
ferred that the space you have given to the puerperal diseases 
had been devoted to obstetrics. But others may think differ- 
ently; and the busy practitioner may choose to have the mate- 
rial pertaining to child-bed included in the same volume. Brief 
as your discussion of the subject necessarily is it will be a God- 
send to many a poor doctor and to many a poor mother who is 
in need of help. 

Of the general therapeutics of the work I shall be excused 



INTRODUCTION. XXiii 

from saying very much. The indications that you have given 
and emphasized are simple and practical. There is a commend- 
able absence of fine-spun theorizing, and of controversy, and a 
calm, straightforward commendation of the remedies which the 
general professional experience has often tested, and upon which 
we must continue to rely until we are certain of having found 
something better. It is still a question in obstetrics, as it is in 
gynaecology, where surgical interference should end and thera- 
peutical means should be exclusively depended upon. Until this 
question is settled we will surely do well to present the claims 
of both these kinds of resource as fairly as possible, and then 
leave it to the judgment of the practitioner to adapt the one or 
the other, or both, to the case in hand. 

Without a further reply to your kind and touching dedication, 
permit me, my dear doctor, to thank you most heartily, and to 
wish you an abundant measure of success and prosperity in your 
double capacity of teacher and physician. 

E. Ludlam. 

Chicago, Nov. 3, 1882. 



THE 

SCIENCE AND ART OF OBSTETRICS, 

PART I. 

ANATOMY AND PHYSIOLOGY OF THE FEMALE 
GENERATIVE ORGANS. 



CHAPTEE I. 

Anatomy of the Pelvis. 

The pelvis is a part of the human body, a knowledge of which 
is of the highest value to the obstetrician. Indeed, so essential 
is a comprehensive and explicit acquaintance with it, that with- 
out thorough conversance with its structure and relations, no 
one is qualified to practice midwifery with any degree of satis- 
faction to either himself or his patrons. 

The pelvis constitutes a bony case or basin, within, and upon 
which, are all the organs directly concerned in the process of 
reproduction. Not only this, but through the canal which it 
forms, the foetus passes in the act of parturition. 

Component Parts of the Pelvis. — In the adult, it is composed 
of four distinct bones, namely : the two ossa innominaia, the 
sacrum and the coccyx. The ossa innominaia are united ante- 
riorly, and, from their peculiar form, constitute the anterior and 
lateral walls of the pelvis. Posteriorly these bones articulate 
with the sacrum, which is interposed between their extremities. 



26 ANATOMY OF THE PELVIS. 

The coccyx is joined to the sacrum inferior ly in such a manner 
as to continue and complete the latter' s structure. 

The os innominatum is formed by the union of three parts, 
the ilium, ischium and pubis, the perfect fusion of which gives 
to the bone a form unlike that of any other in the human frame. 
Osseous union of the parts is completed about the twentieth 
year. 

The Os Innominatum. This bone is so irregular in shape, 
that a description of it, however carefully given, would utterly 
fail to convey to the mind a clear conception of its anatomical 
characters, without the aid of a specimen or drawing. It is 
truly the nameless bone. It is formed of three parts, distinct in 
the infant and young child, united at the acetabulum, at first by 
cartilaginous, but eventually by osseous structures. The lines 
of junction form a figure resembling the letter Y, but, after com- 
plete ossification, they become almost wholly obliterated. 

These three portions of the os innominatum have been named 
1 . the os ilium, hip, or haunch bone, 2 . the os ischium, or sit- 
ting bone, and 3 . the os pubis, pecten or share bone. 

Fig. 1 




The right os innominatum, — outer surface 

Its outer surface. — The chief obstetric interest in connec- 
tion with the innominate bone is directed to its inner surface. 



THE OS INNOMINATUM. 27 

Upon its outer surface are attached certain muscles, some of 
which render powerful aid in parturition, but most of them play 
no important part in the act. Among the former may be men- 
tioned the muscles forming the abdominal wall, a portion of 
whose attachment is to the crest of the ilium; and also those 
muscles attached to the tuberosity of the ischium and which 
contribute to form the pelvic floor. Looking at its outer super- 
ficies we observe the broad, flat ilium, the bent ischium, and the 
projecting pubis, while at the point where these several parts 
are united, is the smooth, round depression known as the ace- 
tabulum or cotyloid cavity into which is received the head of the 
femur. We also notice, in the dried specimen, an aperture situ- 
ated between the pubis and ischium, which, in the recent subject, 
is filled, or covered, with a membrane or ligament, and which 
gives to the opening its name, — the obturator foramen. A small 
aperture only is found superiorly, which serves to transmit 
the obturator vessels and nerve. 

Fig. 2. 




The right os innominatum, — inner surface. 

Its Inner Surface. — Bringing under view the inner surface, 
we observe that the bone is divided into a superior and an infe- 
rior part, by a ridge which traverses it transversely. This is 
termed the ilio-pectineal line, taking its name from the iliac and 
pubic portions of the os innominatum. On the lower and pos- 
terior part of the ilium is a roughened, ear-shaped surface, being 
the portion of the bone which articulates with the sacrum, and 



28 ANATOMY OF THE PELVIS. 

known as the auriculo-articular surface. These features being 
given, no further study need now be made of the os innomina- 
tum as a whole. Its several parts, however, are worthy further 
attention. 

The Os Ilium. — This is the larger of the three, of a triangu- 
lar shape, situated superiorly, and, with its fellow of the oppos- 
ite side, forming what is called the false pelvis. It presents an 
irregular, convex, external surface, with elevations and depres- 
sions which afford attachments for the glutei muscles. Its op- 
posite or internal surface is smooth and concave, forming a fossa 
for the broad, flat iliacus internus muscle. It is united to the 
other parts of the innominate bone at its lower anterior margin, 
by what is termed the body or base, which is thicker than other 
parts. The ilium being broad and flattened, forms an ala or 
wing. Its superior margin, thickened into a lip for the attach- 
ment of certain muscles, is termed the crest. Upon the promi- 
nent anterior margin there are two eminences — one above, and 
the other below, known as the anterior superior, and anterior 
inferior spinous processes. The body of the bone is divided 
from the wing on the inner surface by a well-defined ridge, 
which forms part of the ilio-pectineal line, and marks the 
boundary of the true pelvis. 

The Os Ischium.— This bone is situated anteriorly and in- 
feriorly to the ilium, and is joined to it at the acetabulum by its 
body. Projecting forward and upward from the base, which is 
the thickest and strongest part of the structure, is a thinner por- 
tion, the ascending ramus. This is united to the descending 
ramus of the pubis, and aids in forming the obturator foramen, 
and pubic arch. Between the two extremities of the ischium is 
a thick, strong portion, projecting downwards, and constituting 
the most inferior part of the pelvis. This, from its form, is 
called the tuberosity of the ischium. Pointing downwards, back- 
wards and inwards from the body of the bone, is a point of con- 
siderable obstetric importance, since it has been termed "the 
key to the mechanism of labor" — i. e., the spine of the ischium. 

The Os Pubis.— This is a light, V shaped bone, situated most 
anteriorly, articulating with the ilium and ischium at the acetab- 
ulum, and with its fellow anteriorly. The body of the bone, at 
its acetabular articulation, is the thickest part, while from this 



THE SACRUM. 29 

there extends forwards and inwards a thinner part which is the 
horizontal ramus. The articulation of the pubis with its fellow 
of the opposite side is called the symphysis pubis, and from this 
part of the bone there stretches downwards, backwards and out- 
wards, a thin plate, the descending ramus, which joins the 
ascending ramus of the ischium. The superior margin of the 
pubis forms a continuation of the ilio-pectineal line, and near 
the symphysis pubis is an elevation — the spine of the pubis — to 
which is attached Poupart's ligament, and near it the pectineus 
muscle. The pubis by its anterior articulation forms that im- 
portant pelvic feature, the pubic arch. 

In figure 1 is shown the outer surface of the os innominatum. 
(1) is the ilium, (2) the acetabulum, (3) the crest of the ilium, (4) 
the anterior superior spine, and (5) the anterior inferior spine of 
the ilium, (16) the horizontal ramus of the pubis, (18) the descend- 
ing ramus of the pubis, (19) the spine of the pubis, (20) the obtu- 
rator foramen, (15) the ascending ramus of the ischium, (14) the 
tuberosity of the ischium. 

Figure 2 shows the inner surface of the os innominatum. (1) 
is the articular surface of the ilium, (2) the ascending ramus of 
the ischium,(3)the spine of the pubis, (4) the anterior superior, 
and (5) the anterior inferior spine of the ilium, (6) (7) the 
posterior, superior and inferior spines of the ilium, (8) the sciatic 
notch, (10) the iliac fossa, (12) the ilio-pectineal line, (13) the 
spine of the ischium, (16) the junction of the ascending ramus 
of the ischium, and descending ramus of the pubis, (20) the 
obturator foramen. 

The Sacrum, or basilaire. It is difficult to understand why 
this bone should have received a name indicating a quality 
of holiness, for sacrum means holy, and that so general an 
idea of sanctity should have been connected with it in ancient 
times, and by many different nations. It may be related in 
some way to the belief current among the Jews that " there is a 
small bone in the body which is indestructible, and which at the 
resurrection will gather about it, as to a centre, all the other 
parts of the body and rise bodily into everlasting life." 

The sacrum is a triangular bone, forming the base or lower 
termination of the spinal column, and binding together the 
ossa innominata. It is composed originally of five separate 
vertebrae of graduated sizes, which by their junction resemble a 



30 ANATOMY OF THE PELYIS. 

pyramid, with the apex downward, its base forming a seat or 
plinth, on which rests the last lumbar vertebra. The seams be- 
tween the several vertebras thus united, are distinct, and the 
edges of the bones form prominences easily felt on vaginal 
examination. The sacrum presents six surfaces for study, all of 
which are, in their main characters, of some interest to the 
obstetrician. The bone is bent somewhat longitudinally, and 
slightly so from side to side, with the concavity looking inwards. 
Its superior, inferior and lateral surfaces are articular. The 
superior surface, or base, articulates with the last lumbar verte- 
bra by means of an inter-articular disk of cartilage, and thus 
forms the lumbo-sacral or sacro-vertebral joint. The interven- 
ing cartilaginous disk, from being thicker anteriorly than 
posteriorly, causes the base of the sacrum to project more than 
it otherwise would. This part of the bone, thus rendered pro- 
minent, is known as the promontory of the sacrum. The 
superior portion of either lateral surface articulates with the 
ilium to form the ilio-sacral synchondrosis. The small, thin 
apex articulates with the coccyx below, and thereby forms the 
sacro-coccygeal joint. 

Looking at the inner surface of the bone, we discover on either 
side of the bodies of the fused vertebras, four openings, formed 
by the transverse processes. These are the sacral foramina, and 
transmit the anterior sacral nerves, which contribute to the for- 
mation of the great sciatic nerve, that passes down the outside 
of the thigh. The concavity formed by the sacral curves is known 
as the hollow of the sacrum. This surface of the bone is compar- 
atively smooth, thereby favoring an easy passage of the foetus 
through the pelvic canal. 

The outer surface presents an entirely different aspect, being 
rough and tuberculous. In the median line are the spines of 
the vertebras, while on either side are discovered openings 
which correspond to those on the inner surface, and which serve 
to transmit the posterior sacral nerves. The roughness of the 
posterior surface serves a wise purpose, since the tubercles give 
firm attachment to ligaments and muscles of much power and 
importance. The entire bone is penetrated longitudinally by 
the spinal canal, which contains the terminal nerves of the spi- 
nal cord, known as the cauda equina. 



THE COCCYX. 31 

The Coccyx, or huckle-bone, is a small bone, originally com- 
posed of four rudimentary vertebrae, which do not become ossified 
into one piece until middle life. In shape it somewhat resembles 
the sacrum, and is so articulated as seemingly to form a part of 

Fig. 3. 



The anterior surface of the sacrum. 

that bone. It may be regarded as the tail-bone of the species. 
Like the sacrum, it is turned with the base upwards, and apex 
downwards. Two styloid processes project from the posterior 
lateral surfaces, to rest upon the back part of the apex of the 
sacrum, and prevent too great repression of the point of the 
bone during the descent of the foetus. There are correspond- 
ing cornua on the opposing part of the sacrum. The curve 
begun by the sacrum is so far extended by the coccyx, that the 
latter bone is made to form part of the pelvic floor. Its apex 
represents the posterior pole of the conjugate diameter of the 
outlet, which diameter is considerably amplified during expul- 
sion of the foetus, by a recession of the apex, movement taking 
place at the sacro-coccygeal joint. 



32 



ANATOMY OF THE PELVIS. 



CHAPTEK II. 



The PeMc Articulations. 



Having viewed the separate bones which make up the pelvis, 
we may now consider the articulations which result from their 
association. We shall notice, 1, the symphysis pubis; 2. the 
ilio-sacral synchondroses; 3. the sacro-coccygeal articulation, in 
each of which the obstetrican will take interest. 

The Symphysis Pubis is the articulation situated directly 
in front, and resulting from the approximation of the two pubic 
bones. The articular surface of the bones is but small, since 
the bone itself at this place is comparatively thin. This surface 
is invested with fibro-cartilage, which is thickened anteriorly, 
where the surface comes in contact with its fellow, and thinned 
posteriorly, so as to leave a space, which is lined by a synovial 
membrane. 

Fig. 4. 




Section of the Symphysis Pubis. 

The bones thus articulated form an arch, called the pubic 
arch, the crown of which is directly at the symphysis. It is 
highly important that the student bear in mind the existence, 
situation and form, of this arch, inasmuch as under it the foetal 
occiput glides in favorable terminations of vertex presentations. 
A shortening of the span of the pubic arch operates to increase 



THE PELVIC ARTICULATIONS. 



33 



the pelvic depth anteriorly, and adds greatly to the difficulties 
and dangers of parturition. 

The Ilio-Sacral or Sacro-Iliac, Synchondroses. — Attention 
has already been directed to the auriculo-articular surfaces 
of both the ilium and sacrum, the junction of which make the 
joint under consideration. The bones once in position, we have, 
then, two synchondroses (so called) the right and the left. The 
articular surfaces are, in the recent subject, covered with fibro- 
cartilages, and there is found between them, as in the other pel- 
vic articulations, a serous membrane, which becomes most distinct 
during the latter part of pregnancy. 

Fig. 5. 




Section through the left sacro-iliac articulation. (Natural size 



Mechanical Relations of the Sacrum.— If we regard the 
sacrum as does Dr. Matthews Duncan,* as a strong transverse 
beam, curved on its anterior surface, with its extremities in con- 
tact with the corresponding articular surfaces of the ossa in- 
nominata, important mechanical relations are sustained by the 

* " Researches in Obstetrics," p. 67. 



34 ANATOMY OF THE PELVIS. 

ilio-sacral synchondroses. The weight of the body is trans- 
mitted to the innominate bones, and through them to the ace- 
tabula and femurs. Counterpressure is there applied, and the 
result is an important modifying influence on the development 
and shape of the pelvis. 

The Sacro-Coecygeal Joint.— This is a ginglymoid Joint, 
formed by the articulation of the bones from which its name is 
derived. There is no doubt that by means of it considerable 
mechanical advantage to labor is derived. When the long 
diameter of the head in its descent rotates into the conjugate of 
the pelvic outlet, the latter diameter, by movement backward of 
the coccyx under pressure, is capable of amplifying the neces- 
sary dimensions, and thereby facilitating foetal escape. This 
movement, however, is not confined to the joint itself, but is 
generally shared by the points of ossification of which the coccyx 
is made up. This is especially true of the second and third and 
first and second pieces. 

The articular surfaces here are likewise covered with cartilage, 
and between them is found a serous membrane. 

Abnormal Deviations. — Eelaxation, or violent disruption of 
the pubic joint and of the ilio-sacral synchondroses has been 
described by several. The most pronounced symptom in such 
cases is the difficulty, or impossibility, of sitting or standing 
erect. There is generally pain or uneasiness in the pelvic region, 
and a sense of weakness and unsteadiness in the bones. Relief 
can usually be afforded by a tight bandage about the hips. This, 
and absolute rest, constitute the best treatment. Inflammation 
and suppuration of the pelvic joints is an occasional occurrence. 
When recognized, the pent up matter should be drawn away, and 
constitutional treatment adopted. 

Anchylosis of the sacro-coccygeal joint, and premature ossifi- 
cation of the separate pieces of the coccyx, may take place, and 
give rise to much delay, difficulty and suffering during descent 
of the head. Such anchyloses have been known to snap under 
pressure, with a report which was audible. During instru- 
mental delivery a rupture of the kind may take place, and thus 
permit the rapid completion of the process. In all such cases a 
certain amount of attention should be bestowed on the repara- 



THE PELVIC LIGAMENTS. 35 

tive process, to prevent reunion of the parts with the coccyx in 
an unnatural position. 

The Ligaments of the Pelvis. — These are by no means few 
in number, when those which are in close relation to the articu- 
lations are included. The symphysis pubis receives strength from 
ligaments stretched from one bone to the other on every side of 
the joint. We therefore have superior and inferior, inner and 
outer ligaments. Of these, the posterior is a layer of fibres 
of little strength; the superior is connected with a band of fibres 
which arises from the spine of the pubis, and conceals the irreg- 
ularities of the crest of the bone. The anterior is a layer of 
irregular fibres passing across from one side to the other, and 
crossing obliquely the corresponding fibres from the other side; 
and the inferior, triangular, or subpubic ligament is so thick, 
and so formed by its attachments to the rami of the pubes, as 
to give smoothness and roundness to the subpubic angle, and 
thereby to facilitate the passage of the foetus. 

The ligaments which stay the ilio-sacral synchondroses are so 
arranged as to give the articulation great strength. The poste- 
rior sacro-iliac ligament consists of strong irregular bands of 
fibres, which pass from the overhanging portion of the ilium, to 
the contiguous rugged projections on the lateral surface of the 
sacrum. One of these bands, prolonged from the posterior su- 
perior iliac spine, to the third or fourth vertebra of the sacrum, 
in a direction different from the other fibres, is known under the 
name of the inferior, or oblique, sacro-iliacligament. The ante- 
rior sacro-iliac ligament is a simple fibrous lamina, extended 
transversely from the sacrum to the os innominatum. It is rather 
an expansion of the periosteum, than a true ligament. The 
superior sacro-iliac ligament is a very thick fasciculus, passing 
transversely from the base of the sacrum to the posterior part of 
the inner surface of the bone. 

These synchondroses are strengthened also by the sacro-sci- 
atic ligaments, — greater and lesser. The greater or posterior, 
arises from the posterior margin of the ilium, including the 
posterior inferior spine, and from the lateral surface of the sa- 
crum and coccyx. It is broad and flat, but its fibres converge as 
they pass downwards, and forwards, to be inserted into the inner 
surface of the ischial tuberosity. The anterior or smaller sacro- 
sciatic ligament is triangular in shape, but shorter and thinner 



36 ANATOMY OF THE PELVIS. 

than the other. The origin of its base is blended with that of 
the greater, but is less extensive, and its apex is attached to the 
spine of the ischium. 

These ligaments transform the sciatic notch into two foramina, 
the greater and the lesser sacrosciatic. Through the former of 
these pass the pyrif ormis muscle, the great sciatic nerve, and the 
ischiatic and pudic vessels and nerves. Through the latter pass 
the obturator internus muscle, and the internal pudic vessel and 
pudic nerve. 

The function of these ligaments is tersely put by Leishman* as 
follows : — " They act, as has already been mentioned, by pre- 
venting the displacement of the apex of the sacrum upwards and 
backwards, an accident which, without their aid, the very oblique 
position of that bone would, in the erect posture, be likely to 
engender; and therefore, in this sense, they strengthen the sacro- 
iliac articulation. But, in addition to this, they close in, in some 
measure, the large irregular opening which constitutes the out- 
let of the pelvis, forming, at the same time, the framework of 
those soft structures which constitute the floor of the pelvis, 
which exercise a very important influence on the progress of 
labor; and which act also by affording an efficient and elastic 
support to organs which would otherwise be liable to frequent 
displacement downwards." 

The ligaments which strengthen the lumbosacral joint are 
similar to those which join one vertebra to another. The ante- 
rior common vertebral ligament passes over the surface of the 
joints, and we also find the ligamenta sub-flava and the inter- 
spinous ligaments, as in the other vertebrse. The articular pro- 
cesses are joined together by a fibrous capsule, and there is also 
a peculiar ligament, the lumbosacral, stretching from the trans- 
verse process of the last lumbar vertebra, on each side, and at- 
tached to the side of the sacrum and the sacro-iliac synchon- 
drosis. Note should also be made of the ilio-lumbar ligament, 
which passes from the apex of the last lumbar vertebra to the 
thickest portion of the iliac crest. 

The ligaments of the sacro-coccygeal articulation require but 
brief notice. The anterior ligament consists of a few parallel 
fibres which descend from the anterior part of the sacrum to the 
corresponding face of the coccyx. The posterior sacro-coccygeal 

*" System of Midwifery." p. 40. 



MOVEMENTS OF THE PELVIC BONES. 37 

ligament is flat, triangular, broader above than below, and of a 
dark color. Arising from the margin of the inferior orifice of 
the sacral canal, it descends to, and is lost on, the whole poste- 
rior surface of the coccyx. It aids as well in completing the 
canal behind. These ligaments seem to embrace the entire 
joint in a kind of capsule. 

A few words remain to be said regarding the obturator liga- 
ment or membrane. As has been elsewhere stated, this struct- 
ure is stretched over the obturator foramen, almost closing it, a 
small opening only being left for the passage of the obturator 
vessels and nerves. It may be said of this membrane, however, 
that it is rather an aponeurosis than a ligament. 

Movements of th^ Pelvic Articulations. — There is a popu- 
lar notion among people of nearly all nations, and has been 
from time out of mind, that, during labor, there is extensive 
movement and separation of the pelvic bones. It has been ques- 
tioned by many capable of forming an intelligent opinion on the 
subject, that, with a single exception, any movement or divarica- 
tion occurs. Action of the coccyx on the sacrum has been ad- 
mitted, but motion of the bones at the other joints has been 
doubted. The consensus of opinion, however, among the best 
authorities, endorses the conviction that movement of the sort 
in question, does take place. At the symphysis pubis the 
ligaments are softened, and, under pressure, there is slight sepa- 
ration. At the sacro-iliac synchondroses similar relaxation of 
ligamentous structures occurs, the articular surfaces are sun- 
dered in a minute degree, and then there is performed an oscil- 
lation of the sacrum on its transverse axis. The sacro-sciatic 
ligaments share in the general relaxation, and thereby give 
greater freedom to the action. Zaglas* first called attention to 
the fact that, notwithstanding the intimate union of the bones at 
the sacro-iliac articulation, they still possess a certain degree 
of mobility. In man he found, that under certain conditions, 
as in defecation, the oscillation amounted to about a line. Dr. 
Matthews Duncan describes a similar, but exaggerated, movement 
as taking place in the parturient woman, and indicates the 
advantages thereby afforded, and the conditions which favor it. 
Thus at the beginning of labor, as the head enters the brim, the 

*" Monthly Journal of Med. Science," Sept., 1831. 



38 



ANATOMY OF THE PELYIS. 



woman instinctively prefers to sit, to walk, or, if to lie, to do so 
with the lower limbs extended, positions which favor the rotation 
backward of the sacral base, 'and consequent increase of the con- 
jugate diameter of the brim. 



Fig. 6. 




But when the head reaches 
the pelvic floor, and begins 
to engage the outlet, there is 
a manifest disposition of the 
woman to bend the body for- 
ward, and flex the thighs, con- 
ditions which favor extension 
of the conjugate diameter of 
the infesior strait by a rota- 
tion of the sacrum on its trans- 
verse axis. 



Diagram showinj 
merit of the sacrum. 



the oscillatory move- 



The Pelvis as a Whole. — Having made a somewhat detailed 

Fig. 7. 

SL 




The articulated Pelvis, 
study of the several bones, joints and ligaments, which contrib- 
ute to form the pelvis, let us now view it as a whole, and note its 



THE PELVIS AS A WHOLE. 



39 



remarkable characters. And as we do so, first of all we will 
observe that by means of the constriction which is represented 
by the ilio-pectineal line and sacral promontory, which is 
also the superior strait, or pelvic brim, the pelvis is naturally 
divided into superior and inferior parts, the former being 
termed the false pelvis, and the latter the true pelvis. In the 
living, or recent subject, then, the false pelvis would.be bounded 
anteriorly by the abdominal walls, laterally, by the broad flat 
wings of the ilia, posteriorly by the lumbar vertebrae, and the 
posterior portion of the ilia, and inferiorly by the plane of the 
superior strait, or pelvic brim. The true pelvis is bounded pos- 

Fig. 8. 




Showing the Diameters of the Superior Strait, 
teriorly by the sacrum, laterally by the ishia and bodies of the 
ilia, anteriorly by the pubes, superiorly by the brim of the pelvis, 
or superior strait, and inferiorly by the outlet or inferior strait. 
The broad, expanded alas of the ilia, the ischial tubers, the 
sacral promontory, and the pubic arch, are all peculiarities of the 
structure that should be noticed. Within the true pelvic cavity, 
the hollow of the sacrum, formed by the curve of that bone, and 
the ishial spines, demand special attention. We shall shortly 
enter upon a more minute study of the pelvic cavity, a part 
replete with interest, since through it passes the foetal head and 
trunk during parturition. 



40 



ANATOMY OF THE PELVIS. 



Measurements of the PeMs. — Before proceeding further, 
the student will do well to familiarize himself with the dimen- 
sions of the pelvis. In giving these, certain terms will be used 
which require definition. 

Referring now to figure 8 we have a diagram of the superior 
strait, or pelvic brim; a-b represents the antero-posterior, or 
conjugate diameter, the poles being the symphysis pubis and 
sacral promontory; c—d designates the transverse diameter; f-e 
shows the left-oblique diameter, the poles resting at the right 
acetabulum or ilio-pectineal eminence, and the left sacro-iliac 
synchondrosis; f-c marks out the right-oblique diameter, the 
poles being found at the left ilio-pectineal eminence, or left 
acetabulum, and "the right sacro-iliac synchondrosis. 

With regard to exact dimensions we should recollect that they 
can scarcely be given with any degree of confidence, inasmuch 
as actual measurements are found to be so various. It is only 
by taking the average diameters of a large number of pelves 
that we can arrive at a clear comprehension of pelvic dimensions. 



Fig. 9. 




Showing the Diameters of the Outlet. 



But what is of vastly greater importance than exact figures for 
the student of obstetrics to remember, are the relative measure- 
ments. In the figures, which follow, reference is had to the 
dried pelvis, divested of all soft parts save ligaments. 



THE PELVIC DIAMETERS. 41 

Before submitting the figures, however, a word is required 
with regard to the oblique and conjugate diameters of the pelvic 
cavity and outlet. In the instance of the former, one pole 
necessarily rests on the sacro-sciatic ligaments, and hence is not 
fixed. This is also true of the conjugate of the outlet, one pole 
of which diameter rests on the tip of the coccyx, and this, as has 
been explained, is pressed more or less backwards during de- 
scent of the fcetal head. 

The following will then approximate the actual diameters, in 

inches, of the true pelvic cavity, and of its superior and inferior 

straits : — 

Conjugate. Transverse. Oblique. 

Brim, or superior strait 4J b\ 5 

Cavity ' b\ 5 {5\) 

Outlet 5 to 6 4| (4|) 

Other pelvic measurements are also submitted: — 

Circumferential measurement of the brim , 17 

Measurement from the sacral promontory to the centre of the acetabulum, 

or the ilio-pectineal eminence 3^ 

Between the widest part of iliac crests lOf 

" anterior superior iliac spines loj 

" front of symphysis and sacral spines 7 

From the diameter of the true pelvis, as given, it will be 
observed that at the brim the conjugate is the shortest, and the 
transverse the longest. In the recent subject, however, these 
relative dimensions are changed. The transverse diameter, from 
encroachment of the psose and iliac muscles, becomes shorter 
than the oblique. Moreover, on account ot the presence of the 
rectum on the left side of the sacral promontory, the left oblique 
diameter is rendered shorter than the right. 

Inclination of the Pelvis. When the pelvis is placed upon a 
flat surface, so that the ischial tubers and coccygeal tip are 
brought upon the same plane, we do not get an accurate idea of 
the position which this part of the skeleton really occupies in 
the living, erect subject. Without entering into a narrative of 
the different notions which have from time to time been held on 
this subject, it will answer practical purposes to say that the pel- 
vis is so placed that, in the erect position, what are termed its 
horizontal planes, sustain a marked inclination. This is an im- 
portant consideration, and should be clearly comprehended. 



42 



ANATOMY OF THE PELVIS. 



Now it has been found that, while the inclination of the pel- 
vis varies in different persons, and in the same person at differ- 
ent times, the general pitch of the plane of the superior strait is 
at an angle of say 60°, and the plane of the inferior strait, before 
recession of the coccyx, is at an angle of say 11° with the hori- 
The high practical value of these items of information 



zon. 



will be clearly discerned as we proceed. 




SUSJHED BACK 



OBSTETRICAL CONJUGATE, 
H0BIZ0N. 



Planes of the Pelvis. It is not difficult to demonstrate what 
is meant by pelvic planes. That of the superior strait would be 
well represented by a piece of card-board fitted into the irregu- 
lar outline of this aperture. In a section of the pelvis, the plane 
of the brim would be represented by a line drawn from the su- 
perior margin of the pubes to the promontory of the sacrum. A 
piece of card-board fitted into the outlet, so that one side of it 
would rest on the point of the coccyx, and the opposite side at 
the crown of the pubic arch, extending between the ischial tubers, 
would represent the plane of the outlet. This plane, in a sec- 
tion like that in figure 10, would be represented by a line drawn 
from the sub-pubic margin to the tip of the coccyx. 



THE PELVIC AXIS. 



43 



Other planes, without number, may be created within the 

pelvic cavity, by carrying forward the lines representing the 

Fig. 11. 
c 



A. B.. Horizon 

C. D. Vertical line. 

A. B. I. Angle of inclination of 
pelvis to horizon, equal to 60°. 

B. I. C. Angle of inclination of 
pelvis to spinal column, equal 
to 150°. 

C. I. J. Angle of inclination of 
sacrum to spinal column, equal 
to 130°. 

E. F. Axis of pelvis inlet. 

L. M. Mid plane in the middle 

line. 
N. Lowest point of mid plane 
of ischium. 



planes of the superior and inferior straits to the point of inter- 
section, and from this, as a focus, radiating other lines through 
the pelvis, as shown in figure 12. 

Axis of the Parturient Canal. The axis of the parturient 
canal is its geometrical centre. To demonstrate the axis of a 
perfect cylinder would not be difficult, but the parturient canal 
is a cavity of irregular dimensions, with diameters short in one 
part and long in another, and a depth much greater posteri- 
orly than anteriorly. The axis of the brim would be represented 
by a line drawn through its centre, perpendicularly to its plane, 
and which would extend from the umbilicus to the coccyx. The 
axis of the outlet of the bony pelvis intersects this, and extends 
from the promontory of the sacrum through the geometrical 
centre of the plane in question. 

What is known as the "curve of Carus," was at one time 
generally supposed to represent the axis of the pelvis. It is formed 
in the following manner : The compasses are expanded so that 
when one point is placed at the middle of the posterior surface of 
the symphysis, the other will rest midway upon the conjugate di- 




44 



ANATOMY OF THE PELVIS. 



ameter. The latter point is then made to describe a curve through 
the pelvic canal, and the line resulting is- the curve sought. For 
practical purposes this will answer, yet it cannot be regarded 
as the real pelvic axis, since the posterior wall of the cavity 
has not a uniform curve. It is only by creating a large num- 
ber of artificial planes like those represented in figure 12, 
and determining the geometrical centre of each, that we ap- 

Fig. 13. 



Fig. 12 




proximate exactness. A line drawn through the centres of such 
planes, from pelvic inlet to outlet, would be found to describe an 
irregular parabola, which would represent the true axis of the 
pelvic canal. 

It must not be supposed that the plane of the bony outlet 
truthfully represents the plane upon which the foetal head passes 
the vulva. The yielding pelvic floor is greatly stretched, and if 
the posterior boundary of the plane be the posterior vaginal 
commissure, we discover that the plane would form with the 
horizon an angle of 75 ° or 80 ° . This is fully set forth in. 



THE PELVIC AXIS. 



45 



figure 13 ; a-b is the newly formed plane of the vulva, r is the 

anus, and e the line representing the axis of the parturient 

canal 

Fig. 14. 

The Inclined Planes. — When 

we look at a section of the pelvic 
canal, like that here shown, we ob- 
serve that the lateral wall is easily 
divided into two parts, by a line 
extending, naturally from the ilio- 
pectineal eminence to the ischial 
spine, b-a. That part of the bone 
in front of the line looks slightly 
forward; that behind the line looks 
slightly backward. These are the 
anterior and posterior inclined 
I planes of the ischium, supposed by 
many to determine the rotation of 
the foetal head in the pelvic cavity. 
Male and Female Pelvis. — With dried specimens before us, 
it is apparent, even on a cursory comparison, that there is a 

Fig. 15. 





difference between the male and female pelvis. In order to ren- 
der the variations explicit in detail, the following contrast has 
been drawn : 



46 



ANATOMY OF THE PELVIS. 
Fig. 16. 




Comparison of the Male and Female Pelvis* 



FEMALE. 

1. All the bones are comparatively 
light in structure, and the points for 
muscular attachments are only mode- 
rately developed. 

2. The iliac wings are widely spread, 
so that when seen from before, the 
broad expanse of the iliac fossae comes 
plainly into view. 

3. The ischial tuberosities are wide- 
ly separated, so as to give a transverse 
diameter at the outlet of 4f inches. 

4. The sub-pubic angle is obtuse 
(90° to 100°), and the span of the arch 
broad. 

5. The pelvic cavity is wide and 
shallow, and the sectional area of the 
brim and outlet about equal. 



6. The sacrum is broad, and its 
promontory moderately prominent. 

7. The obturator foramen are trian- 
gular in form. 

8. The spines of the ischia have a 
moderate projection into the pelvic 
cavity. 



MALE. 

1. All the bones are comparatively 
heavy in structure, and the points for 
muscular attachments are well devel- 
oped. 

2. The iliac wings not so widely 
spread. 



3. The ischial tuberosities com- 
paratively near, giving a transverse 
diameter at the outlet of say 3£ or 4 
inches. 

4. The sub-pubic angle is acute (70 
to 75°), and the span of the arch nar- 
row. 

5. The pelvic cavity is narrow and 
deep, and the sectional area of the out- 
let considerably below that of the 
brim, giving to the pelvis a funnel 
shape. 

6. The sacrum is comparatively nar- 
row, and the promontory very prom- 
inent. 

7. The obturator foramen are more 
oval in shape. 

8. The ischial spines are remarka- 
bly prominent. 



THE EXTERNAL GENERATIVE ORGANS. 47 

These differences between the male and female pelvis are 
probably the result of the growth and development of the female 
internal generative organs, situated within the true pelvis. 
Schroeder, in proof of this, calls attention to the fact that in 
women with congenital defects of these organs, and in women 
who have had both ovaries removed in early life, the general 
form of the pelvis is masculine. 



CHAPTEE III. 

The Female External Generative Organs. 

Division According to Function and Situation. — The female 
generative organs have been divided according to situation and 
function into external and internal organs. The external organs 
are those which are in view externally, and together constitute 
the pudendum. They are concerned mainly in the copulative 
act, but through them passes the foetus in parturition. They 
consist of the mons veneris, the vulva, the vagina and the per- 
ineum. The internal generative organs are concerned mainly in 
producing the ovum, developing and ultimately expelling it. 
They consist of the ovaries, the uterus and the Fallopian tubes. 

The Mons Yeneris. — This is a cushion-like eminence situated 
directly upon the symphysis pubis and the horizontal pubic rami. 
It is composed mainly of adipose and fibrous tissue, and serves 
as a protection to the parts during sexual intercourse. At pu- 
berty it develops a growth of hair, the area thus covered form- 
ing a pyramid with the apex at the vulva. Numerous sweat and 
sebaceous glands are found to open on its integument. 

The Yulva. — The vulva is made up of a variety of parts. The 
labia major a are two rounded folds of connective tissue contain- 
ing a variable amount of fat, elastic tissue, and smooth muscular 
fibres. They originate anteriorly, at the posterior margin of the 
mons veneris, and, lying side to side, extend posteriorly, and 
finally unite at the anterior margin of the perineum to form the 
posterior commissure of the vulva. The margins which lie in 
contact, and the entire inner surfaces, are covered with mucous 
membrane, while the external surfaces are provided with ordi- 



48 



ANATOMY OF THE PELVIS. 



nary integument. They are broad and flat in front, i. e., at the 
anterior commissure, but thin and narrow posteriorly. The in- 
tegument for a certain distance from the mons veneris is 
thinly covered with hair, and is provided with a considerable 
number of sweat and sebaceous glands. The external labia, or 
labia majora, in the mature virgin, conceal the other vulvar 
structures, but in women who. have borne children they are not 
so close, and between them may be seen the labia minora. In 
young girls also, and old women the labia minora protrude. 

The Clitoris. — Separating the labia majora we find just be- 
hind the anterior vulvar commissure, a small elongated body, 
called the clitoris. On careful examination, it is found to resem- 
ble the penis in form and structure, and like the male organ is 
the seat of the aphrodisiac sense. It differs from the penis in 
having neither corpus spongiosum nor urethra. It is divided 
into the crura, the corpus and the glans. The crura are long, 
Fig. 17. 



Lateral view of the erectile structures 
of the female external organs. The skin 
and mucous membrane have been re- 
moved and the blood vessels injected, a. 
yjbulbus vestibuli ; v. plexus of veins called 
^ the pars intermedia; e. glans clitoridis; 
/. corpus clitoridis ; h. dorsal vein ; I. right 
m cms clitoridis ; m. vestibulum ; n. right 
gland of Bartholin or Duverney. 



spindle-shaped processes, attached to the borders of the ascend- 
ing rami of the ischia and the descending rami of the pubes. 
The corpus is formed by the junction of the crura in the med- 
ian line, just beneath the pubic arch. The glans is the rounded, 
imperforate extremity. During erection the clitoris attains the 
size of a small pea. The mucous membrane covering of the glans 
is of a pale, red color, and contains papillae, part of which are 
provided with vessels, and part, nerve endings, similar to those 
found in the nipple. 




THE EXTERNAL GENERATIVE ORGANS. 
Fig. 18 



49 




The external organs. 6, labia majora; g, vestibule ; c, posterior commis- 
sure and fourebette ; d, perineum ; <?, anus. 



50 ANATOMY OF THE PELVIS. 

The Labia Minora. — The labia minora, or nymphse, are two 
folds of mucous membrane, which arise on either side from the 
centre of the internal surface of the labia major a. They extend 
forward, forming folds of considerable breadth, and finally unite 
at the clitoris. As they approach this organ they bifurcate, the 
posterior branches being attached to the clitoris, and the anteri- 
or uniting to form a sort of prepuce for the organ. In some 
women, even in middle life, the labia minora become quite 
elongated, and protrude a considerable distance. This is 
especially true of some of the negro races. As elsewhere stated, 
in adult virgins they are covered by the external labia, but in 
women who have borne children, in the aged and in young girls, 
they show themselves in the rima pudendi. In young girls and 
virgins, the mucous membrane covering their surfaces is of a 
light pink shade, but in others it is brown, dry, and like skin in 
appearance. The mucous membrane is provided with tessellated 
epithelium, and a large number of vascular papillae. On their 
inner surfaces are a large number of sebaceous glands, which 
secrete an odorous, cheesy matter, that serves for lubrication and 
prevents adhesion of the folds. 

The Yestifoule. — The vestibule is a smooth, mucous surface, 
triangular in form, with its apex to the clitoris, lying between that 
organ and the anterior margin of the vaginal orifice. It is 
bounded on either side by the folds of the nymphse, and 
posteriorly by the vaginal orifice. The mucous membrane of 
the vestibule is smooth, and unlike the mucous membranes of 
other vulvar parts, is destitute of sebaceous glands. There 
are a few muciparous glands opening on its surface. At the 
centre of the base of the triangle formed by the vestibule, 
is situated an opening, the location of which should be famil- 
iar to the physician, namely, the meatus urinarius or meatus 
urethrce. From this external opening the urethra passes 
upwards and backwards under the pubic arch, in the tissues 
which form the anterior vaginal wall, a distance of about one 
and one-half inches, to the bladder. It is composed of mus- 
cular and erectile tissue, and is remarkably dilatable. With the 
finger in the vagina, it can be plainly felt in the situation des- 
cribed. 

Vaginal Orifice. — The opening of the .vagina is directly be- 
hind the vestibule. Its lateral boundaries are the labia minora 



THE EXTERNAL GENERATIVE ORGANS. 



51 



for but a short distance, and the labia major a in the main. Its 
posterior boundary is the fourcheite. In an undilated state it is 
a mere fissure, which varies considerably in size. 



Fig. 19. 



Fig. 20. 





Figures showing different forms of the hymen. 

The Hymen is a structure of variable thickness and strength, 
situated just within the vagina, and was formerly regarded as a 
seal of virginity. When intact, and of ordinary form, it serves as 
a complete bar to introception of the male organ, but it is fre- 
quently ruptured in infancy or childhood from accidental 
causes. When incomplete, or anomalous in structure, sexual 
congress may be held, and impregnation follow, without its 
destruction. There are also well authenticated cases on record, 
of pregnancy existing in women with this part not only of usual 
proportions, but with only small perforations. It is generally 
cresentic in form, with the free border turned toward the 
anterior vaginal wall. In the main its structure is such, being 
chiefly a fold of mucous membrane with some cellular tissue and 
muscular fibres, together with vessels and nerves, *that it yields 
readily to firm pressure. In other cases, however, instead of 
being thus constructed, it is firm and strong, requiring an in- 
cision to displace it. Anomalies in form are not uncommon. 



* Budin has shown that it is really a part of the vaginal orifice. " Progres 
Medical," 1879. Nos. 35, etc. " Contraeblatt fur Tynak." vol. iv. p. 12. 



52 ANATOMY OF THE PELVIS. 

Instead of presenting a free border anteriorly, it may be pro- 
vided with a central opening of differing size, or there may be a 
number of small openings, rendering it cribriform. Cases of 
imperforate hymen are also mot. 

Carunculae Myrtiformes. These are small fleshy tubercles, 
from one to five in number, situated about the vaginal orifice. 
They are generally regarded as remains of the ruptured hymen. 
*Schroeder does not concur fully in this opinion. " In primi- 
parse," he says, " portions of the torn hymen are suffused with 
blood (during labor), and destroyed by gangrene, so that in the 
vulva some warty, or tongue-like projections remain. (Caruncu- 
lae myrtiformes. ) His views are supported by Lusk and others. 

The Fossa Navicularis. — In women who have never borne a 
child there still romains a fold of mucous membrane at the 
posterior margin of the vaginal orifice, which has been termed 
the fourchette or framum. Situated between this and the 
posterior vulvar commissure is a little fossa, called the fossa 
navicularis. In nearly all first labors the fourchette is torn. 

The Secretory Apparatus. — Sebaceous glands are most 
abundant in the tissues of the nymphae, where they furnish 
a fatty, yellowish-white material, possessing a peculiar odor. 
This material, when accumulated beneath the prepuce of the cli- 
toris, constitutes the smegma preputii, so common in women 
who neglect the niceties of the toilet. They are also present, as 
stated, though in fewer numbers, on the mons veneris, and labia 
majora. Mucus glands, five to seven in number, are found 
irregularly distributed about the meatus urinarius. They are 
of the compound racemose variety, about the size of a poppy- 
seed, and possess short, wide ducts with large orifices. They 
are of aid to the beginner in locating the meatus urinarius for 
cathoterism, though Tyler Smithf says that one of these single 
lacunae may be sufficiently dilated to admit the point of a small- 
sized catheter, thus constituting a deception and snare. 

The YulYO-Yaginal Glands were first discovered by Bartho- 
lin, and have been called "the glands of Bartholin." The name 
of Duveney has also been attached to them. They are two in 
number, of the size of a small bean, and somewhat resembling it 
in shape, of a reddish-yellow color. They are situated near the 

* Manual of Midwifery, p. 102. 

f Manual of Obstetrics, p. 22. 



THE EXTERNAL GENERATIVE ORGANS. 



53 



posterior part of the vaginal orifice, behind the posterior extrem- 
ities of the bulbi vestibuli, which they partially overlap. They 
are conglomerate glands, and are the analogues of Cowper's, 
glands in the male. Internally they are of a yellowish-white 
color, and composed of a number of lobules separated from each 
other by prolongations of the external envelope. The several 
lobules give origin to separate ducts, which unite in a common 
canal about half an inch in length, which opens in front of the 
attached edge of the hymen in virgins, and in married women 
at the base of one of the carunculae myrtiformes. They secrete 
a yellowish adhesive fluid, which is freely poured out during coi- 
tus and labor. Its office is a protective one, as it renders the. 
mucous surfaces moist and slippery. They are more developed 
in young girls than in women of middle life, while in old age 
they in some cases disappear altogether. 

The Bullbi Yestibuli. The bulbs of the vestibule are two 
curved, leech-shaped masses of reticulated veins, about an inch 
in length, situated between the vestibule and pubic arch on. 

Fig. 21. 




Vascular supply of Vulva, (After Kobelt, 



A. pubis; B. B. ischium; C. clitoris; D. gland of the clitoris; E. bulb; 
F. constrictor muscle of the vulva; G. left pillar of the clitoris; H. dorsal- 
vein of the clitoris; M. labia minora. 

either side. They are covered internally by the mucous mem-, 

brane, and embraced on the outside by the fibres, of the constric- 



54 



ANATOMY OF THE PELVIS. 



tor vaginae muscle. Kobelt claims that they correspond to the 
two separated halves of the male bulbus urethrae. The anterior 
ends, which are rather small, are connected by means of the 
pars intermedia with the glans clitoridis. It is by means of 
this erectile tissue that erection of the clitoris takes place. The 
blood, during sexual excitement, is pressed through this connec- 
tion by the reflex action of the musculus constrictor cunni, from 
the turgid bulbs into the glans clitoridis. These highly erectile 
tissues are supplied with blood from the internal pubic arteries. 

The Yagina. — This important part of the female generative 
apparatus is by some classed with the internal genitals, but it is 

here considered as an external organ. 
It is a cylindrical membranous tube, 
extending from the vulva to the uterus, 
and is sometimes called the vulvo- 
uterine canal. It is situated in the 
pelvic cavity, with the bladder ante- 
riorly, and the rectum posteriorly, 
and, when put upon the stretch, ex- 
tends from the vulva to the superior 
strait, following pretty closely the 
general curve of the pelvic axis. The 
walls, while strong, are soft and yield- 
ing, and lie in contact, being flat- 
tened from before backwards. There 
has been considerable discussion over 
the length of this organ, and it is quite 
certain that the measurements given 
by some are excessive. When not 
drawn forcibly out to its greatest 
length, it can be fully explored with a 
finger measuring three or three and a 
half inches; but, when at its maximum, 
the length is probably four to four and 
a half inches— possibly five. Its meas- 
urement varies greatly in different 
women. The canal is sometimes very 
short, its length being only one and a 
half or two inches. It is united to the bas-fond of the bladder 




The vagina, (after removal 
of posterior wall). Ou, mea- 
tus urinarius. Oue, external 
os uteri. B, section of wall at 
the fornix vaginae. (Henle). 



THE EXTERNAL GENERATIVE ORGANS. 55 

by condensed areolar tissue, while the urethra is situated in its 
anterior wall. Behind, it is connected with the rectum, in its su- 
perior part, by a double fold of peritoneum, and in its inferior 
portion by areolar tissue. Its lateral borders afford attachment 
above to the broad ligaments, and below to the pelvic areolar 
tissue and some venous plexuses. The superior extremity, or 
fornix, embraces the cervix uteri in such a way as to give a 
supra-vaginal portion, and an intra-vaginal portion. The su- 
perior boundaries of the vagina in thus folding upon them- 
selves to embrace the neck, form a circular groove or cul-de-sac, 
described as the anterior and posterior vaginal cul-de-sacs. 
The posterior ' is generally double the depth of the anterior. 

The orifice of the vagina is bounded by the labia minora and 
vestibule. It differs considerably in size and appearance in 
young girls, in virgins, in women accustomed to sexual 'nter- 
course, and in those who have borne children. Most of thegM 
facts have already been pointed out. Erroneous ideas are some' 
times derived from the vagina being described as a tube with an 
external opening. It is a tube or canal, but one whose walls 
normally lie in contact. 

The vagina is composed of an external, a middle, and a 
mucous coat. The external consists of cellular tissue, which con- 
nects it anteriorly with the bladder and urethra, laterally with 
the levator ani, and posteriorly with the rectum and peritoneum. 
The walls are not of uniform thickness. In the upper part of 
the canal the internal surface is very smooth, and the walls are 
only half a line to a line in thickness. The external cellular tis- 
sue coat is very elastic, and affords a fine bed for the vaginal 
bloodvessels. The middle coat is muscular, tho fibres being of 
the involuntary variety. They run in both longitudinal and 
transverse directions, and are so interlaced that a dissection into 
separate layers is impossible. The connective tissue and mus- 
cular layers increase in thickness as they approach the vaginal 
orifice. Luschka* has described a circular bundle of voluntary 
fibres, the sphincter vaginal surrounding the lower extremity of 
the vagina and urethra. The action of this muscle not only nar- 
rows the vaginal orifice, but likewise serves to close the urethra 
by compressing it against the urethro-vaginal septum. The mid- 
dle coat of the vagina is dense and fibrous like the proper tissue 

* " Die anatomie des menschlichin Becl'ens" Fiibingen, 1864, p. 387. 



5Q 



ANATOMY OF THE PELVIS. 



of the uterus, and is continuous with it at the os and cervix 
uteri. Cruveilhier, and other anatomists, have compared it to 
the dartos. The mucous lining of the vagina has, upon the lower 
portion of its anterior and posterior walls, two thickened ridges, 
which are found in the median line. These are termed the col- 
amnce rug arum or vaginal columns. The anterior is more prom- 

Fig 23. 




Section of female pelvis. 1, rectum. 2, uterus. 3, cul-ae-sac of Douglas. 
4, vesico-uterine space. 5, bladder. 6, clitoris. 7, urethra. 8, symphysis. 
9, sphincter ani. 10, vagina. (Kohlrausch modified by Spiegelberg. ) 



inent than the posterior, and is sometimes divided into two 
portions by a longitudinal furrow. From these two columns pro- 



THE EXTERNAL GENERATIVE ORGANS. 57 

ject folds of mucous membrane at nearly right angles, which are 
heavier and more numerous in the lowermost part of the vaginal 
canal. The rugce, or cristce, as some prefer to call them, are 
most distinct in virgins, less so in women who are accustomed 
to sexual intercourse, and are nearly absent in women who have 
borne children. The vagina also becomes smooth in virgins 
after the time of child-bearing has passed. The designs of these 
mucous folds are to afford increased sensational area, and more 
particularly to provide against rupture of the vaginal mucous 
membrane during the immoderate distention which takes place 
in labor. According to Henle,* the muscular fibres of the 
vaginal columns possess a trabecular arrangement, and inclose 
offshoots from the vaginal plexus. Though thus constructed, the 
columns are not properly erectile. When turgid with blood, 
they close the vagina, but the resistance they offer is not for- 
midable, since, like a sponge, they are easily compressed. Mic- 
roscopical examination discloses a large number of vascular pap- 
illae studding the mucous membrane of the vagina, which under 
certain conditions, as those of pregnancy, become greatly en- 
larged, so that to the examining finger they seem hard and 
rough. Writers have frequently described the vagina as con- 
taining great numbers of mucous follicles, to which is attributed 
the secretion of the mucus which lubricates the vagina. It has 
now become a conviction (unsettled, however, by some doubt,) 
that there are no secreting glands. Dr. Tyler Smith, who was 
one of the first to deny their existence, says:f "The mucus 
of the vagina is, I believe, produced by the epithelium, and con- 
sists of plasma and epithelial particles." This thin layer of 
mucus which covers the vagina even in periods of repose, is, as 
was pointed out by M. Donne and Dr. Whitehead, distinctly 
acid. Under sexual excitement, menstruation, and during par- 
turition, the amount of the secretion is greatly increased. 

The lining coat of the vagina resembles ordinary skin almost 
as much as mucous membrane, and in cases of procidentia, where 
it is exposed, it becomes converted into dermoid tissue. -The 
vaginal mucous membrane is covered with squamous epithelium, 
and is reflected over the vaginal portion of the cervix and os 
uteri. 

* " Handbuch der Eingeweidclehre des Menschen," Braunschweig, 1866, p. 450. 
t Lectures on Obstetrics, p. 57. 



58 



ANATOMY OF THE PELVIS. 



The vagina is abundantly supplied with vessels and nerves. 
The blood is derived from the internal iliac artery, and returns 
by means of corresponding veins. The arteries form an intri- 
cate network around the tube, and eventually end in a sub-mu- 
cous capillary plexus, from which twigs pass to supply the papillae. 
These in turn again give origin to the venous radicals, which 
unite into meshes, freely interlacing with each other and form- 
ing a well-marked venous plexus. 

The Perineum. — The perineum is one of the most important 
structures in connection with the female generative apparatus, 
and hence merits most careful study. It is situated between the 

Fig. 24. 



CLITORIS. 




URETHRA, 



CONSTRICTOR 
GUNN1 M. 



TRANSVERSA 



Muscles of the Perineum. 



posterior vaginal commissure and the anus below, and between 
the vagina and rectum above. It presents three surfaces for study, 
namely, the vaginal, extending upwards from the posterior vulvar 



THE EXTERNAL GENERATIVE ORGANS. 59 

commissure for a distance into the recto-vaginal septum, the 
rectal surfaces extending from the margin of the anus upwards 
into the recto-vaginal septum, while the third is that which 
stretches externally between the posterior vaginal commissure 
and the anus. The last is that generally considered, and meas- 
ures about one inch in length.* During labor this is greatly 
increased. The perineum is a body of considerable thickness, 
but during expulsion of the f cetal head it \ becomes greatly 
thinned and elongated, so that the measurement given, is in many 
cases far exceeded. 

The structure of this body is chiefly skin, cellular tissue, 
muscular fibres, and mucous membranes. The arrangement of 
the perineal muscles deserves notice. They are inserted by at 
least one extremity into tendonous structures and fasciae. This 
is true of the sphincter ani, levator ani, coccygei, transversi per- 
perinaei, erectores clitoridis, and sphincter vaginae. The fibres 
which are associated to form these several muscles, are indis- 
tinct when compared with other muscles, and are mixed up with 
a good deal of elastic dartoid tissue. The peculiar construction 
of the perineum is what gives to it the quality of distensibility, 
which is manifested during parturition. 

The most important structure which forms a part of the per- 
ineum, is the levator-ani muscle. This muscle has a double 
structure, is attached anteriorly to the inner surface of the bodies 
and horizontal rami of the pubes, and its lateral halves to the 
tendinous arch of the pelvic fascia, which stretches from the 
inner border of the pubes to the ischial spines. The fibres of 
the muscles stretch anteriorly downward and inward to the sides 
of the bladder and. rectum, and are inserted posteriorly into a 
tendonous raphe, which extends from the tip of the coccyx to the 
rectum. The fibres extending to the rectum become blended 
with those of the external sphincter, while thofte in relation with 
the vagina are situated beneath the bulbs of the vestibule, and 
the constrictor cunni. The ischio-coccygeus, a small muscle, is 
by some included in a description of the levator ani. It requires 
no detailed notice. 

* Foster, F. P. " Anat. of the Uterus and its Surroundings." " Am. Jour, 
Obs.," January. 1880. 



60 



ANATOMY OF THE PELYIS. 




Fig. 21 
A portio vaginalis. B, corpus uteri. C, fun- 
dus. ' D, Fallopian tubes. E, fimbria. F, ovaries. 
G, parovaria. H, round ligaments. I, vagina. 
K, labia majora. L, labia minora. M, clitoris. 
N, hymen. (Beigel.) 



THE INTERNAL GENERATIVE ORGANS. 61 

The levator ani and coccygeus muscles are of nearly membran- 
ous thinness, and derive their chief strength from the strong 
tissues of the internal pelvic fascia, to which they are closely 
attached. 

- The other muscles which contribute to form the perineal floor 
are of slight obstetric importance. They are chiefly the ischio- 
cayernosi, the constrictor vaginae, and the transversi perinaei. 
The ishio-cavernosi muscles form a sheath about the crura of the 
clitoris. The constrictor vaginae is made up of two small lateral 
muscles which lie upon the outer side of the vestibular bulbs, 
and surround the vulvar orifice. The transversi perinaei mus- 
cles are small, triangular, thin muscles, passing from the inner 
sides of the ischia, underneath the constrictor muscle, to the 
side of the vagina and rectum. 

It remains to be said of the perineal body that it occupies, as 
stated, the space between the vagina and rectum, and in a sagit- 
tal section presents a tri-angular shape, with a convex vaginal, 
and concave rectal, surface. It extends up the recto- vaginal sep- 
tum, nearly half the length of the vagina. 

The functions of the perineum are chiefly two: 1. It closes 
the lower outlet posteriorly, so as to prevent prolapse of the 
pelvic viscera; 2, it admits of distension when necessary, and, 
by its elasticity, speedily resumes its former condition. 



CHAPTER IY. 

The Internal Female Generative Organs. 

The Uterus. — About this wonderful organ more obstetric 
interest centres than about any other in the female economy. It 
is pear-shaped, flattened somewhat ' antero-posteriorly, and bent 
slightly on its longitudinal axis, its concavity looking forwards. 
The uterus in the virgin differs in shape and size from that in 
the woman who has borne children. In the description, which 
follows, reference is made only to the nulliparous organ. Its 
length varies from two, to two and a half inches, its average 



62 



ANATOMY OF THE PELYIS. 



breadth at the widest point is about one and a half inches, while 
its thickness is about three quarters of an inch. Its upper 
border is moderately convex/ and its lateral borders are convex 
above and concave below. At the points of junction of the 
lateral and superior borders, the Fallopian tubes pass into the 
uterus. The points are called angles or cornua. The lower 
portion of the organ is spindle-shaped, and has a width of say 
half an inch. 

By reason of its peculiar form the organ is naturally divided 
into two portions of nearly equal length. The lower portion is 
called the cervix, or neck. The upper portion is subdivided, and 
that part lying below the Fallopian tubes is known as the corpus 
or body, while that situated above the Fallopian tubes is 
distinguished as the fundus. 

The lower part of the cervix is em- 
braced by the upper extremity of the 
vagina, and this intra- vaginal end of 
the cervix is known as the vaginal 
portion. The remainder of the cer- 
vix, which lies above or without the 
vagina, is distinguished as the supra- 
vaginal portion. At the lowermost ex- 
tremity of the cervix there is a slight- 
ly transverse aperture, called the ex- 
ternal os, or os Uncce. It is very 
small, measuring not more than two 
lines in width, and sometimes scarce- 
ly admitting the point of a small uter- 
ine sound. This uterine mouth is 
provided with two thick rounded lips, 
the anterior being a little the longer. 
In the adult female the uterus is 
situated in the true pelvis, between 
the bladder in front and the rectum 
behind. In the non-pregnant condition it is wholly within the 
pelvic cavity, the fundus being below the plane of the superior 
strait. The mechanism, by which the organ is held in position, 
should be thoroughly comprehended. Lying, as it does, approx- 
imately in the axis of the pelvic canal, it is to a certain extent 




Anterior view of Virgin 
Uterus, (Sappey). 1, body. 2. 
2, angles. 3, cervix. 4, site 
of os internum. 5, vaginal 
portion of cervix. 6, external 
os. 7, 7, vagina. 



THE INTERNAL GENERATIVE ORGANS. 63 

supported by the vaginal walls and columns, while the latter de- 
rive much of their supporting power from the perineal body. 

The Uterine Ligaments, from their peculiar arrangement, 
give to to the organ a considerable freedom of movement, while 
in health, they serve to prevent serious deviations of position or 
situation. Most of these are formed by folds of the great serous 
membrane which wraps the pelvic viscera, namely, the periton- 
eum. This membrane, after covering part of the posterior sur- 
face of the bladder, is reflected upon the anterior face of the 
uterus, covering a greater share of its superficies. It then passes 
over the fundus uteri, and down the posterior surface, dipping to 
a considerable depth, and forming posteriorly to the upper part of 
the vagina a serous pouch, bounded laterally by folds of the peri- 
toneum. This pouch is the cul-de-sac of Douglas, and the folds 
of peritoneum which form its lateral boundaries are the retro- 
uterine, or utero-sacral ligaments. Anteriorly to the uterus — 
that is, between the uterus and bladder — is a shallow pouch with 
similar ligamentous boundaries formed by the peritoneum, the 
latter being known as the vesico-uterine ligaments. The peri- 
toneum being a broad sheet or apron, forms by its duplicatures 
as it passes over the pelvic organs as described, broad-folds upon 
both sides of the uterus, stretching from this organ to the pelvic 
wall, known as the ligamenia lata or broad ligaments. These di- 
vide the pelvis into two cavities — the anterior of which lodges 
the bladder, and the posterior, the rectum. The superior border 
of the broad ligament is free, and extends from the angle of the 
uterus to the iliac fossa. The two serous folds which constitute 
the broad ligament, are separated by a loose, and very extensible, 
lamellated cellular tissue, continuous with the proper fascia of 
the pelvis. The broad ligaments' disappear during gestation, 
their two laminae assisting to cover the anterior and posterior 
faces of the enlarged uterus. 

The round ligaments, or supra-pubic cords, are structures 
which differ entirely from those just described, being evidently 
continuous with the uterine tissues. They arise from the upper 
border of the uterus, and extend transversely, and then obliquely, 
downwards, until they pass through, the inguinal rings, and 
blend with the cellular tissue of the mons. veneris and labia. 
In passing through the inguinal rings each is invested with a peri- 
toneal sheath called the canal of Nuck. Their upper portion is 



6J= 



ANATOMY OF THE PELVIS. 



made up solely of the unstriped variety of muscular tissue; but, 
as they descend, they receive striped fibres from the transvers- 
alis muscles, and the columns of the inguinal rings. They also 
contain elastic and connective tissue, and^ arterial, venous and 
nervous branches, the first being derived from the iliac or cre- 
masteric arteries, and the last from the genito-crural nerve. 

The uterus thus held by its ligaments is in a freely mobile 
state, it being a wise provision for protection from injury that 
might otherwise arise from. violent physical exertion, falls, jars, 

Fig. 27. 




B, median section of virgin uterus. C, transverse section, (Sappey). B, 1,1. 
profile of the anterior surface. 2, vesico-uterine-cul de sac. 3, 3, profile of poste- 
rior surface. 4, body. 5, neck. 6, isthmus. 7, cavity of the body. 8, cavity 
of the cervix. 9, os internum. 10, ant. lip of os externum. 11, posterior lip. 
12, 12, vagina. C, 1, cavity of the body. 2, lateral wall. 3, superior wall. 
4, 4, cornua. 5. os internum. 6, cavity of the cervix. 7, arbor vitse. 8, os 
externum. 9, 9, vagina. 

and other disturbing occurrences. As previously stated, its 
longitudinal axis corresponds pretty closely to the axis of the 
pelvic canal, but the fundus of the organ is, in most cases, 
slightly inclined to the right. 

The Uterine Cavity. — Lateral section of the organ discloses 
a cavity corresponding in form to the uterus viewed as a whole. 
Its widest measurement is at the superior angles, where minute 
orifices mark the openings of the Fallopian tubes. The narrow- 
est point is at the junction to the body and cervix, at which 



THE INTERNAL GENEEATIVE OEGANS. 65 

place the cavity is a very narrow passage, distinguished as the 
internal os. Between this point and the os tincse there is a wider 
channel, known as the cervical canal. A converse longitudinal 
section reveals but a small cavity, with the anterior and posterior 
walls lying in contact. 

Structure of the Uterus. — Three principal structures enter 
into the composition of the uterus — namely, peritoneal, muscu- 
lar, and mucous. The manner in which the peritoneum invests 
the organ has been described with sufficient minuteness for prac- 
tical purposes. Almost the entire organ is covered by this mem- 
brane. The investment at the sides is less extensive than else- 
where, since the peritoneal folds separate a short distance below 
the Fallopian tubes, and there the nerves and vessels which sup- 
ply the organ gain entrances. The peritoneum, as it covers the 
upper portion of the uterus, becomes firmly adherent to it, while 
below it is more loosely connected. 

The Muscular Structure. — The proper tissue of the uterus 
is of a grayish color, and is very dense in structure, creaking 

Fig. 28. 




Muscular fibres of unimpregnated uterus, (Farre). <x, fibres united by con- 
nective tissue. &, separate fibres and elementary corpuscles. 

like cartilage under the scalpel. The cervix is generally less 
firm than the body, a condition resulting, as M. Cruveilhier 
believes, from the body and fundus being the more frequent seat 
of sanguineous fluxions. Under physiological, as well as patho- 
logical conditions, the tissue presents a more marked redness, 
and is more supple. 

The uterine tissue is clearly fibrous in character, but the 
nature of the fibres has been a subject of spirited debate. The 
microscope appears to have ended the dispute by showing them 
to be clearly muscular. This is further shown by the develop- 
ment that takes place during pregnancy, the uterine muscular 
fibres becoming large and powerful. It is certain then that the 




66 ANATOMY OF THE PELVIS. 

proper uterine tissue is chiefly muscular, but the fibres in the 
Fig. 29 non-pregnant organ are condensed or atroph- 

ied, so that their true character is in a meas- 
ure concealed. In the latter condition of the 
organ, the direction of its muscular fibres can- 
not be satisfactorily made out. They cross 
and re-cross, as every examiner has found, in 
an almost inextricable manner. Inasmuch, 
then, as the muscular structure of the uterus 
can be satisfactorily studied only during preg- 
nancy, its further consideration will be de- 
ferred. 

The Mucous Surface.— The existence of 
any mucous membrane whatever on the inner 
surface of the uterus, has been questioned by a 
number, and even recently by Dr. Snow 

Developed muscular Beck* who insists that what has been so re- 
fibres from the gravid . 

uterus, (Wagner.) garded is nothing more noi less than soften- 
ed proper uterine tissue. Authorities in general, however, do 
not concur in this belief, but agree that it is essentially a 
mucous membrane, differing from mucous membrane in other 
parts chiefly in being more intimately associated with the 
subjacent structures, in consequence of possessing no definite 
connective tissue frame work of its own. Its color is pale pink. 
Its thickness varies considerably in different parts. Towards 
the middle of the body it constitutes about one-fourth of the 
thickness of the entire uterine walls, being from one-eighth to 
three-sixteenths of an inch in depth. Like the uterine walls 
themselves, it thins off rapidly towards the internal os below, 
and the Fallopian tubes above. In the cervical canal it is thick 
and more transparent than in the body of the uterus. Within 
the cervix the uterine mucous membrane looses many of its char- 
acteristics. On the anterior and posterior surfaces of the canal is 
a prominent perpendicular ridge, with one less distinct on each 
side, from which extend ridges at acute angles. These from their 
appearance, have been called the arbor vitce, penniformrugce, and 
palmae plicatse. Like the vaginal rugae, they are most distinct 
m virgins, and are indistinct after child bearing. The mucous 

* Obstet. Trans., vol. xiii., p. 294. 



INTERNAL GENERATIVE ORGANS. 



67 



surface of the uterus in a normal condition, is covered with a 
thin layer of transparent alkaline mucus. 

The Uterine Glands. — With the aid of a magnifying glass, 
the general structure of the uterine mucous membrane is clearly 
seen. It is made up in part of connective tissue, which is 
directly continuous with the connective tissue of the muscular 
coat, in which, as a bed, are a large number of tubular, or utric- 
ular, glands. About forty-five of them are contained in a space 
one-eighth of an inch square. These glands have a sinuous 
course, often divide below into two or three separate blind 
extremities, and are about one two hundred and twentieth of an 
inch in diameter. As a rule they penetrate the entire thickness 
of mucous membrane, and in some instances even dip into the 
muscular tissue. Their basement membrane is composed of 
spindle-shaped cells, which dove-tail into one another. Their 
free surface is covered with cylindrical cells, possessing ciliae. 
The mucous membrane itself possesses an epithelial covering, of 
the ciliated variety, which is believed by some to produce a cur- 
rent in the direction of the Fallopian tubes. 

The glands of the cervix, (glands of Na- 
both, ) cover the entire area of the cervical 
canal, from the internal os to the borders of 
the external. They differ from those found 
within the uterine cavity. Like them they 
are cylindrical, but terminate in a rounded 
cul-de-sac, lentil-shaped. These glands are 
so numerous that, according to Dr. Tyler 
Smith, " on a moderate computation, under 
a power of eighteen diameters, ten thousand 
mucous follicles are visible in a well-devel- 
oped nulliparous organ." " These glands," 
says Dr. Lusk, "are, genetically consid- 
ered, simple inversions of the mucous mem- 
brane, and are lined by ciliated epithelium." 
Obstruction of the neck of these glands gives 
rise to straw-colored vesicles, which have 
been called the ovula of Naboth. The pen- 
Section Through "ute- niform ™g® g ive to the cervical canal an 
rus, showing cavity, a, extensive secretory surface, which furnishes 

and glandular struct- -,-, v ^ „„..„ 

ures, I. (Heber). an alkaline mucus. 




68 ANATOMY OF THE PELVIS. 

The Yessels of the Uterus. — The uterus receives its blood 
from two sources, viz.: 1. the two ovarian, or spermatic 
arteries, and 2. the two uterine. The origin of the ovarian 
arteries is about two-and-a-half inches above the aortic bifurca- 
tion. They pursue a serpentine course, descending obliquely 
downwards under the peritoneum to the pelvic cavity, and then 
ascending between the folds of the broad ligaments. They then 
reach by their main trunks the sides of the uterus, and communi- 
cate with the uterine arteries. The uterine arteries are derived 
from the hypogastric. Their course is at first to the vaginal 
fornix where they give the "vaginal pulse." Thence they curve 
upwards between the folds of the broad ligament, and pass in a 
tortuous course over the lateral borders of the uterine cervix and 
body. By means of a circumflex branch at the junction of cervix 
and corpus uteri, the arteries of each side communicate. 

Fig. 31. 

6 




Arterial vessels in a uterus ten days after delivery. The posterior aspect is 
shown. 1, fundus uteri; 2, vaginal portion; 3, 3, round ligament; 4, 4, fal- 
lopian tubes; 5, right ovary; 6, abdom. aorta; 7, inf-mesenteric art; 8, 8, 
spermatic arteries 9, common iliac. 10, ext. iliac; 11, hypogast. art. 

The veins of the uterus form a network through all the uterine 
tissues. They are so intimately related to the latter that they 
remain open after section. They enlarge during pregnancy to 



THE INTERNAL FEMALE GENERATIVE ORGANS. 



69 



form "sinuses." The blood, collected by the veins, is carried 
into two venous plexuses, namely: the uterine and pampiniform. 
The latter returns blood from the uterus, Fallopian tubes and 
ovaries, but the former from the uterus only. 

Fig. 32. 




Nerves of the uterus. A, plexus uterinns magnus; B, plexus hypogastrieus; 
C, cervical ganglion. 1, sacrum; 2, rectum; 3, bladder; 4, uterus; 5, ovary; 
6, extremity of Fallopian tube. ( Frank enhaeuser.) 

The Uterine Nerves. — Frankenhaeuser,* who is probably the 
latest and best authority, says that the nerves of the uterus are 



Die Nerven der Gebarmutter," Jena, 186' 



70 



ANATOMY OF THE PELVIS. 



derived from the gangliated cords of the sympathetic system, 
through which important connections are formed with all the 
abdominal viscera. The nerves supplied to the organ, when 
examined without the aid of a lens, are soon lost to sight in the 
uterine walls, but in microscopic preparations, Frankenhaeuser 
has traced their ultimate filaments to the muscular element, 
where they appear to terminate in the nucleus of the fibre-cell. 

It is a conviction of some that there exist in the uterus certain 
ganglionic centres of independent nervous action, like those 
found in the walls of the heart. 

The Lymphatics. — Lymph-spaces abound in the uterine tis- 
sues, and regular lymphatic vessels are found in the connective 
tissue about the arterial trunks in the parenchyma. Beneath 
the peritoneum is found a real network of these vessels. Large 
receiving vessels lie just beneath the external muscular layer on 
either side of the organ, into which the lymph from both the 
subserous and uterine vessels is poured. The lymphatics of the 
cervix pass to the glands of the pelvic cavity. 

Fig. 33. 

t 




Uterus with double cavity, and slight deviation of form. 
Development. — In the embryo the uterus is formed by the 
fusion of the two ducts of Muller, or the efferent tubes of the 
rudimentary generative apparatus. Upon thus uniting, the par- 



THE INTERNAL FEMALE GENERATIVE ORGANS. 



71 



tition between the two is absorbed, and the organ is then pos- 
sessed of but a single cavity. In different stages of development 
there is accordingly an organ of various shape. 

Abnormalities of the Uterus. — The various abnormal con- 
ditions of the uterus and vagina which are occasionally met, are, 

Fig. 34. 




Uterus septus bilocularis. Double uterus, with single vagina, seen from the 
front. Left walls more developed in consequence of pregnancy. (Cruveilhier.) 

in the main, the result of arrested development. After the canal 
or ducts of Miiller have united to form the rudimentary uterus, 
if the partition should remain, the result is a double or bifid 
uterus. This may be true of an organ presenting little differ- 
ence in form from that of the normal uterus, as shown in figure 
33, or the organ may present an external appearance which cor- 
responds to its internal anomalies, as in figure 34. The parti- 
tion may not exist alone in the uterine cavity, but extend down- 
wards, and form a double vagina as well. 

The following constitute the main varieties of abnormalities 
met: 1. The uterus unicornis, or single-horned uterus. In that 
case the organ presents but a single lateral half, and generally 



72 



ANATOMY OF THE PELVIS. 



has but one Fallopian tube. 2. The Duplex Uterus. — Two dis- 
tinct uteri are produced, each of which represents a half of the 

Fig: 35. 




a 

Double uterus and vagina from a girl aged nineteen (Ersenmann). a, double 
vaginal orifice with double hymen ; 6, meatus urethra? ; c, clitoris ; d, urethra ; 
e, e, the double vagina ; /,/, uterine orifices; g, g, cervical portions; h, h, bodies 
and cornua ; i;i, ovaries ; k k, Fallopian tubes; 1,1, round ligaments; m, m, 
broad ligaments. (Courty.) 

normal uterus. 3. The Uterus Bicornis. — This results from 
partial union of the ducts of Miiller, giving to the upper part of 
the organ two horns, divided by a furrow. 4 The Uterus Cor- 
el if or mis. — This, as its name indicates, presents the form of a 
heart as ordinarily represented on playing cards. 5. The Ute- 
rus Sejitus Bihcularis. — Union in this case is complete, but the 
septum persists, as represented in figure 34 



THE INTERNAL FEMALE GENERATIVE ORGANS. 



73 



CHAPTEE V. 



The Internal Female Generative 

Organs.— (Continued. ) 

The Fallopian Tubes^ or Oviducts. — These are the infundib- 
ula or ingluvies which take up and convey the ova from the 
ovaries to the uterine cavity, as well as transmit to the ovaries 
the fecundating principle of the male. They measure from 
three to four inches in length, and extend from the upper angles 
of the uterus to the ovaries. Their course is. along the upper 
margins of the broad ligaments, being covered by the peritoneum 

Fig. 36. 
Od' VI 




Ovary and Fallopian tube, o d, Fallopian tube ; o, ovary ; o a, fimbriated 
extremity of the tube ; p o, parovarium. 

similarly to the uterus. They may justly be regarded as inte- 
gral portions of the latter organ. The Fallopian tubes are trum- 
pet-shaped, and terminate near the ovaries in a comparatively 
broad, fringed end, called the fimbriated extremity, or morsus 
diaboli This free extremity communicates with the abdominal 
cavity. One of these fimbriae is attached to the outer angle of 



74 ANATOMY OF THE PELVIS. 

the ovary by a fold of peritoneum. It is supposed that during 
the menstrual nisus these fimbriae apply themselves firmly to the 
ovary, in order to receive the escaping ovule. Its uterine ex- 
tremity presents an opening known as the ostium uterinum, 
which is so small that it will scarcely admit a bristle. These 
tubes are remarkably movable, so that they are not only capable 
of applying themselves to those parts of their respective ovaries 
from which the ovule is to come, but, as is now believed, to 
stretch themselves to opposite sides to receive an escaping ovule. 
In some cases there are found to exist supernumerary fimbriated 
extremities which communicate with the tube at some distance 
from the main extremity. In the bodies of twenty women, se- 
lected at random by M. Gustave Richard, this anomaly was found 
~Q.ye times. 

The walls of the tubes are composed largely of unstriped mus- 
cular fibres, arranged in two layers — one longitudinal, and the 
other circular. By virtue of these the tubes have a vermicular 
or peristaltic action. Between the muscular and peritoneal layers 
is a web of connective tissue, which gives support to a rich 
plexus of bloodvessels. The raucous membrane lining the cavity 
of the tube is highly vascular, and is provided with ciliated epi- 
thelium, which is said to produce a current in the direction of 
the uterus. 

The Ovaries. — These are regarded as the essential organs of 
generation in the female, since they provide the germ which is 
made fruitful by contact with the male fecundating principle. 
They are the analogues of the testes, and, up to the time of 
Steno, were called "testes mulieris." They are situated on 
either side of the uterus, within the pelvic cavity, and are at- 
tached to that organ by muscular, bands about an inch long, 
called the ovarian ligaments. They are small, oval, flattened 
bodies, broader at the end distant from the womb, their meas- 
urements being about an inch and a half long, about three-quar- 
ters of an inch in breath, and three-eighths to half an inch in 
thickness. They are situated between the layers of the broad 
ligaments, the posterior layer being reflected over the entire or- 
gans, save at the attached borders, at which points openings ex- 
ist for transmission of the spermatic vessels. They lie beneath, 
and somewhat behind the fimbriated extremities of the Fallo- 
pian tubes. Besides the peritoneal coat, they have beneath it 



THE INTERNAL FEMALE GENERATIVE ORGANS. 



75 



another, the tunica albuginea. This covering is so intimately- 
adherent to the subjacent tissues that it cannot be stripped off. 
In the first three years of life it is entirely absent. 

Fig. 37. 



5—1 




Longitudinal section of an ovary from a girl eighteen years old. 1. Albu- 
ginea ; 2, fibrous layer of cortical portion ; 3, cellular layer of cortical portion ; 
4, medullary substance ; 5. loose connective tissue. 

Beneath the albuginea the parenchyma of the organ has an 
outer cortical, and an inner medullary substance. The former is 
of a grayish color, and is made up of interlaced fibres of con- 
nective tissue, containing a large number of nuclei. It is in this 
structure that the Graafian follicles and ovules are found. The 
latter exist in immense numbers in various stages of develop- 
ment, from the earliest periods of life. The stroma of the 
cortical substance is at no place sharply distinguished from that 
of the medullary. In figure 37 the outer portion is termed the 
fibrous layer, to distinguish it from the more central portion, 



76 



ANATOMY OF THE PELYIS. 



there being a difference in its structure. The medullary sub- 
stance has a reddish color, given it by its numerous vessels. It 




Portion of vertical section through ovary of bitch, a, epithelium of ovary y 
Z>, 6, tubules of ovary ; c, young follicles ; d, mature follicles ; e, discus prolig- 
erus, with ovum ; /, epithelium of second ovum in same follicle ; g, tunica 
fibrosa folliculi ; h, tunica propria folliculi ; **, membrana granulosa. (Wal- 
deyer.) 

consists of loose connective tissue, with some elastic, and 
muscular. Rouget* and Kisf claim that the greater part of the 
ovarian stroma is formed of muscular tissue. 



* Journal de Physiol., Vol. i, p. 737. 

f Schultze's Arch. f. Mikrocop. Anat., 1865. 



THE INTERNAL FEMALE GENERATIVE ORGANS. 77 

The Graafian Follicles, or ovisacs. — Waldeyer, and others, 
from pains-taking research, have found that the Graafian fol- 
licles are formed, at an early period in foetal life, by cylindrical 
inflections of the epithelial covering of the ovary, which dip into 
the substance of the gland. These tubular filaments anastomose 
with each other, and in them are formed the ovules, which are 
developed from the epithelial cells lining the tubes. Portions 
become divided from the rest of the filaments, and form the 
Graafian follicles. Accepting this view the ovules must be re- 
garded as highly developed epithelial cells, derived primarily 
from the surface of the ovary. 

The number of Graafian follicles is immense, the ovary at 
birth being estimated to contain not less than 30,000; Henle* 
estimates them at 36,000. No new follicles are formed after 
birth, but development and destruction are constantly going on. 
Of course, but a small proportion of the entire number ever 

Fig. 39. 




DIAGRAMMATIC SECTION OF GRAAFIAN FOLLICLE. 
1, Ovum ; 2 membrana granulosa ; 3, external membrane of Graafian follicle ; 
4, its vessels ; 5, ovarian stroma ; 6, cavity of Graafian follicle ; 7, external cov- 
ering of ovary. 

reach maturity. The greater part of these follicles are not 
visible to the naked eye, but under the microscope they come 
plainly into view. 

The structure of a ripe Graafian follicle is 1. an investing 
membrane, consisting of two layers. The external, or tunica 
fibrosa, is formed of connective tissue, and is highly vascular. 
The internal, or tunica propria, is also composed of connective 
tissue, but contains a large number of fusiform cells and 

* Henle, " Handbuch der Eingcweidelehre," 1866, p. 476. 



78 



THE ANATOMY OF THE PELVIS. 



numerous oil globules. These two layers are really formed of 
condensed ovarian stroma. 2. The membrana granulosa, con- 
sisting of stratified columnar epithelial cells. Near the circum- 
ference of the ovisac is 3. the ovule, around which are congre- 
gated a large number of epithelial cells, forming what is known 
as the discus proligerus. 4 Transparent fluid fills the re- 
mainder of the follicle, with three or four bands, or retinacula 
of Barry, stretched through it, and attached to the opposite 
walls of the cavity. In some young follicles the ovule fills the 
entire cavity. 

Fig. 40. 




Uterine and ntero-ovarian veins (plexus papiniformis). 1, uterus seen from 
the front ; its right half is covered by the peritoneum ; upon the left half may 
be seen the plexus of utero-ovarian veins (internal spermatic) ; 6, utero-ovarian 
vessels covered by peritoneum ; 7, the same vessels exposed ; 8, 8, 8, veins from 
the Fallopian tube ; 9, venous plexus of the hilum ovarii ; 10, uterine vein ; 
11, uterine artery ; 12, venous plexus, covering the borders of the uterus ; 13, 
anastomoses of the uterine with the utero-ovarian vein (int. spermatic). 

The Ovule. — The ovule is a rounded vesicle, about 1-120 of an 
inch in diameter. At the time of its discharge from the ovary it 
is no longer a simple cell, composed of ordinary protoplasm, but 
presents the following characteristics : It has a thick, transparent 
envelope, termed the vitelline membrane, or zona pellucida. The 
body of the cell is the viiellus or yolk. It possesses the proper- 
ties of ordinary protoplasm, has a viscid consistence, and is 
opaque from the presence of very fine granules and globular 
vesicles. The nucleus of the cell becomes converted into a 
large, clear, colorless vesicle, called the germinative vesicle. 
The nucleolus persists as a dark, probably solid body, within the 
germinative vesicle, where it is known as the germinative spot. 
The ovule is attached to some part of the internal surface of the 
Graafian follicle 



THE INTKxl -PELVIC MUSCLES. 



79 



Tessels and Nerves of the Ovary. — The arteries of the ovary 
are derived from the internal spermatic, enter at the hilum and 
penetrate the medullary substance in a spiral course. The 
branches freely anastomose, and form an interlacement. Be- 
tween the vessels, thus connected, are spaces, which become 
smaller and smaller as they approach the surface of the gland. 
The veins begin as radicals, rapidly enlarge, and have a varicose 
appearance. A plexus is formed by anastomosis, including 
spaces of varying sizes. Their blood is then conveyed by veins, 
following the arterial branches, to the internal spermatic vein. 
Lymphatics and nerves exist, but their mode of termination is 
not understood. 

The Intra-pelvic Muscles. — Certain muscles which encroach 
upon the pelvic space should be mentioned. The iliac muscles 
occupy the entire iliac fossae, the fibres converging below, and 

Fig. 41. 



sAcmm 




PYSAMIDALIS.M 



Section of Pelvis, showing the pyramidal muscles. 



passing under Poupart's ligaments, and becoming united to the 
borders of the psoae muscles. These muscles cushion the iliac 
fossae, and thereby afford a soft support for the gravid uterus. 
The great psoae and the iliac muscles encroach more or less 
upon the transverse pelvic diameter at the brim. By virtue of 
their femoral insertions, these muscles serve as flexors of the 
thigh, while, in addition, the iliacus acts as an abductor, and the 
psoas acts as a flexor of the pelvis upon the spinal column. 
The pyramidal muscles close the sacro-sciatic notch. Their 



80 THE ANATOMY OF THE PELYIS. 

shape is triangular, the base presenting a series of digitations, 
which find insertion upon the lateral portions of the anterior sur- 
face of the sacrum, along the outer borders of the four inferior sac- 
ral foramina, and the upper portion of the sacro-sciatic ligament. 
After crossing the greater sacro-sciatic foramen, and emerging 
from the pelvis, they terminate in a tendon, which is inserted 
into the trochanter major. 

The obturator internus muscle arises from the circumference 
of the obturator foramen, and the inner surface of the obturator 
membrane. Its converging fibres form a tendon, which passes 
out through the lesser sacro-sciatic foramen, and is inserted into 
the digital fossa of the great trochanter. None of the intra 
pelvic muscles occupy much space in the pelvic cavity. 

The Mammary Glands. — An account of the female generative 
organs would be incomplete without at least a brief reference to 
the mammary glands. They are two in number, of the com- 
pound racemose variety, are situate on either side of the 
sternum, over the pectoralis major muscles, and extend from the 
third to the sixth rib. They are convex anteriorly, and flattened 
posteriorly. Their size is found to vary considerably, chiefly on 
account of the difference in amount of adipose tissue which 
they contain. During pregnancy they increase greatly in size, 
owing to hypertrophy of the glandular structures. Anom- 
alies in number, shape, and position, are occasionally ob- 
served. They are covered by a fine, supple skin, and a 
layer of adipose tissue, which increases in thickness toward 
the periphery. The glandular mass is made up of from fifteen 
to twenty-four lobes, these being subdivided into lobules, con- 
structed of acini, or minute cul-de-sacs. The acini open into fine 
canaliculi, which unite until they form a large duct for each lobe. 
The ducts in turn unite until they form a still larger duct com- 
mon to the lobe, which opens on the surface of the nipple. The 
latter canals are known as galactophor us, or lactiferous ducts. 
They enlarge as they reach the space beneath the areola to form 
the sinus of the duct, measuring from one-sixth to one-third of 
an inch in diameter. In the nipple, their diameter is from one- 
twelfth to one-twenty-fifth of an inch. The openings on the 
nipple are from one-sixtieth to one-fortieth of an inch in diame- 
ter. The accini are lined with a single layer of small polyhedral 
cells, becoming more cylindrical near the canalicular ducts. The 



THE MAMMAKY GLANDS. 



81 



main ducts are lined with low, cylindrical cells, and are provided 
with non-striated muscular fibres, which contract and produce a 
free now of the secretion during lactation. 



Fig. 42. 




Mammary gland, «, nipple, the central portion of which is retracted ; &> 
areola ; c, c, c, c, c, lobules of the gland ; 1, sinus, or dilated portion of one of 
the lactiferous ducts ; 2, extremities of the lactiferous ducts. (Liegeois.) 

The nipple is situated at the summit of the mamma. It is a 
conical projection, varying greatly in size. Depressed nipples 
are often met, which is a condition generally, though not 
always due to natural causes. Its surface is covered with papillae, 
at the bases of which open the lactiferous ducts. Upon its surface 
are also the openings of numerous sebaceous follicles, the secre- 
tions of which protect and soften the integument during lacta- 
tion. Beneath the skin are muscular fibres, mixed with con- 
nective and elastic tissues, vessels, nerves and lymphatics. Ir- 
ritation of the nipple causes contraction and hardening, owing to 
muscular action. 

The areola is a circle which surrounds the nipple, of a color 
differing from the other integument. It is pink in virgins, and 



82 THE ANATOMY OF THE PELVIS. 

is provided with from fifteen to thirty follicles, which under cer- 
tain conditions pour out their secretions and moisten the areola. 
A band of muscular fibres is found beneath the integument, the 
action of which is to compress the lactiferous ducts, and thus 
favor the flow of milk during lactation. 

The mammae receive their blood supply from the internal 
mammary and intercostal arteries, and are provided with lym- 
phatics, which open into the axillary glands. The nerves are 
derived from the intercostal and thoracic branches of the bra- 
chial plexus. 






PART II. 

PREGNANCY. 
CHAPTER I. 

Development of the Ovum, 

Inasmuch as this branch of obstetrics is of theoretical, rather 
than practical value, to the student of midwifery, and since the 
study of it has been diligently pursued by a few, under most 
favorable auspices, and the results of their investigations re- 
corded, the author has taken the liberty to draw freely from va- 
rious authorities on the subject, sometimes in their own words, 
without, in every instance, giving the credit which may seem 
to be due. 

The anatomy of the ovary with its Graafian follicles and 
ovules has already been given. The formation of the Graafian 
follicles is in the main completed during the ante-natal period 
of existence. Until about the time of puberty they remain in a 
quiescent state, but with its advent they begin to assume func- 
tional importance. The surface of the ovary, when now exam- 
ined, is found to be no longer smooth, but studded with small 
elevations. These elevations are caused by the enlarged Graaf- 
ian follicles, which have approached the periphery, and now 
being distended by their fluid contents, form rounded, translu- 
cent prominences. From disappearance of the blood-vessels and 
lymphatics at the point of pressure, a weak spot in the wall of 
the follicle is formed, called the macula or stigma folliculi. 
The discharge of the ovum is due to the conjoint action of a fatty 
degeneration of the walls of the mature follicle, and the develop- 
ment of the following changes : The follicle becomes congested, 
and the vessels coursing over it loaded with blood, while, at the 
same time, the ovarian covering becomes so thin, that the eleva- 
tion presents a bright red color. Laceration of some of the capilla- 
(83) 



84 THE PHYSIOLOGY OF THE OVUM. 

ries in the inner coat takes place, and a certain quantity of blood 
escapes into the cavity of the follicle. By these means the dis- 
tension is greatly increased, until at last, under the additional 
stimulus of sexual excitement, or without it, rupture occurs, and 
the ovule is set free. Whether laceration takes place before, 
during, or after menstruation, is still an unsettled question. Thin- 
ning of the follicular and ovarian walls goes on at one and the same 
time, and final rupture takes place simultaneously. It is prob- 
able that laceration is further promoted by growth of. the inter- 
nal layer of the follicle, which increases in thickness before 
rupture, and assumes a characteristic yellow color, from the 
number of oil-globules which it contains. Contraction of the 
muscular fibres in the ovarian stroma is also supposed to have 
an influence in the production of laceration. As rupture occurs, 
the fimbriated extremity of the Fallopian tube is closely applied 
to the ovary, receives the freed ovule, and starts it on its way to 
the uterine cavity. . 

The Corpus luteuni of Menstruation. — At the moment of 
rupture, or immediately after it, an abundant hemorrhage takes 
place from the vessels of the follicle, by which its cavity is filled 
with blood. The blood soon coagulates and the clot is retained. 
The aperture through which the ovule escapes is often not more 
than one-fortieth of an inch in diameter. If the follicle is now 
incised longitudinally it will be seen to form a globular cavity, 
one-half to three-quarters of an inch in diameter, containing a 
soft, dark coagulum, lying loosely within it. An important 
change soon begins. The clot contracts and expresses its se- 
rum, which latter is absorbed by the neighboring parts. The 
coloring matter of the blood is also, to a great extent, absorbed, 
so that, at the end of two weeks, a diminution of color is percep- 
tible. The membrane of the follicle becomes thickened and 
convoluted, and encroaches on the cavity. At the end of three 
weeks the follicle has become so solidified that from its color it 
receives the name of corpus luteum. It still continues in rela- 
tion with the ruptured spot on the surface of the ovary, traces of 
which yet remain. On section at this time it presents the 
appearance of a convoluted wall, and a central coagulum. The 
coagulum is semi-transparent, of a gray, or light-greenish color, 
more or less mottled with red. The wall is about one-eighth of 
an inch thick, and of a yellowish or rosy hue. The entire cor- 



THE COKPUS LUTEUM OF PREGNANCY. 85 

pus may be easily enucleated from the ovarian tissue. After 
the third week active retrograde changes begin. The whole 
body undergoes a process of partial atrophy, until at the end 
of the fourth week it is not more than three-eighths of an inch 
in its longest diameter. The color of its walls has also changed, 
it being a clear chrome-yellow. After this period, the process 
of atrophy and degeneration goes on rapidly, until at the end of 
eight or nine weeks, the whole body is represented by an insig- 
nificant cicatrix-like spot, less than a quarter of an inch in its 
longest diameter, in which the original texture of the corpus 
luteum can be recognized only by the peculiar folding and color- 
ing of its constituent parts. It disappears entirely in seven or 
eight months. 

The Corpus Luteum of Pregnancy. — The foregoing shows 
that the mere presence of the corpus luteum is no evidence that 
pregnancy has existed, but only that a Graafian follicle has been 
ruptured and an ovule discharged. There is a difference between 
the corpus luteum of pregnancy, and that of menstruation, and 
yet the difference is not essential or f undimental. It is, properly 
speaking, only a difference in the degree and rapidity of their 
development. It will not be necessary, therefore, to enter upon 
a lengthy description of the appearances and changes, but only 
to note some of the more salient points. At the end of the first 
month, the convoluted wall is bright yellow, and the clot still 
reddish. At the expiration of two months, instead of being 
reduced to the condition of an insignificant cicatrix, it is seven- 
eighths of an inch in diameter. When six months have passed 
it is still as large as before; the clot has become fibrous and the 
convoluted wall paler. At the end of utero-gestation, it is about 
half an inch in diameter; the central clot is but a radiating cica- 
trix, and the external wall is tolerably thick and convoluted, but 
has lost its bright yellow color. The corpus luteum of preg- 
nancy is often termed the true, and that of menstruation the 
false. 

The Migration of the Ovum. — But a small proportion of the 
ova in each ovary ever meet with the conditions requisite for 
fruition. Many doubtless perish in the ovarian stroma, while 
others are doubtless lost in the abdominal cavity, as we learn 
from the occurrence of extra-uterine pregnancy. The precise 



86 THE PHYSIOLOGY OF THE OYUM. 

conditions which determine the passage of the oYum through 
the oviduct to the uterine cavity, are still shrouded in obscurity. 
The theory that by virtue of its erectility the Fallopian tube at 
the proper moment is brought into relation with the ovary 
through its fimbriated extremity, is hardly a tenable one, since 
it has been demonstrated that the tube is not possessed of 
erectile tissue. Rouget* found that injection of its vessels after 
death did not communicate to it the slightest change of form or 
place. Experiments upon the muscular fibres of the tubes has 
brought no better results, as galvanization produced only vermi- 
cular contractions, which did not affect the position of the 
fimbriae, f Moreover, when we reflect on the situation and sur- 
roundings of these tubes, it becomes difficult to understand how 
it is possible for them to execute any very extended movements. 
The theory advanced by Henle that the ovum is drawn into the 
Fallopian tube by currents produced in the serum by the 
ciliated epithelium, which covers both the external and internal 
surfaces of the fimbriae, appears to be gaining favor. Failures 
of the ovum to enter the tube are probably common. 

While the ovum is in the outer portion x>£ the tube, progress is 
made only by the aid of the ciliae ; but when further advanced on 
its way to the uterus, additional force is supplied by the circular 
muscular fibres. 

Fecundation. — Conception, fecundation, and impregnation, 
are terms all of which imply fruitful contact of the male and J 
female elements, so that a new organism comes into existence. 
The precise point at which this takes place has been the subject 
of much speculation and research. It has been pretty clearly 
demonstrated that it cannot be within the uterus, inasmuch as it 
takes the ovum a period exceeding ten days to reach the uterine 
cavity, and an unf ecundated egg cannot sustain life for so long a 
time. Abdominal pregnancies seem to prove the possibility of 
fecundation at the ovary. But, when we reflect upon the rarity 
of such pregnancies, and the strong probability of the frequent 
failure of the escaped ovum to enter the Fallopian tube, we are 

- Eouget" Les Organes Erectiles de la Femme," Jour, de la Physical, t. i. 
1858, p. 337. 

f Hyetl " Handbuch der Topographischen Anatomie." "Wien, 1865. Bd 
tL, p. 210. 

X Leishman, " System of Midwifery," p. 96. 



FECUNDATION. 



87 



led to infer that fecundation at the ovary is anomalous. Henle 
has directed attention to the fact that the outer part of the tube, 
possessing arborescent folds, is- especially designed as a re- 
ceptacle for the seminal fluid. The congested condition of the 
mucous membrane, its canalicular structure, and the contractions 
of its muscular fibres, all seem intended to further the intimate 
contact of the spermatozoa with the ovum after it has reached 
this situation. 

The fecundating principle of the male is secreted in the testes 
at puberty, and is called the semen or seminal fluid. During 
sexual congress the semen is ejaculated with considerable force 
by the fibres of the vasa defer entia and the special muscles which 
surround the vesiculse seminales and the prostate gland. It thus 
reaches the upper part of the vagina, and doubtless sometimes 
even the cervical canal, from which situation the spermatozoa 
ascend to the point of contact with the female ovum. It is, 
however, an established fact, that deposit of the seminal fluid 
deep in the vagina, is not an essential condition to impregnation, 
for pregnancy has been found coexistent with imperforate 
hymen. 

The semen is a thick, glutinous, 
whitish, albuminous fluid, heavier 
than water, and emitting a char- 
acteristic odor. When placed un- 
der a powerful lens it is found to 
consist of a large number of small, 
oval, flattened bodies, measuring 
not more than 1-6000 of an inch in 
diameter, provided with tails which 
taper gradually to the finest point. 
The entire spermatozoon measures 
from 1-600 to 1-400 of an inch. 
These bodies do not passively float in the seminal fluid, but 
move about with a lashing, undulating motion as though 
endowed with volition. The appearance of independent life, 
which they manifest, was what led K'olliker to compare them 
to ciliated cells, and gave the erroneous notion that they were 
anamalcules. The name spermatozoa, which they bear, is sug- 
gestive. Henle, in his " Handbuch der Eingeweidelehre," al- 
ready referred to, has estimated their speed at an inch 




Spermatozoa. 



ill 



88 THE PHYSIOLOGY OF THE OVUM. 

seven-and-a-half minutes. It is doubtless to the spermatozoa 
that the semen owes its fecundating power. Neither is this 
faculty speedily lost, for examinations have demonstrated the 
vitality and activity of these bodies within the female generative 
organs eight and ten days after ejaculation. If, then, the 
spermatozoa are absent from the seminal fluid, as in debility or 
old age, impregnation is impossible, and it is their absence from 
the semen of hybrids that renders these animals sterile. 

Our knowledge of the process of fecundation is very limited, 
the fact only being known that the spermatozoa penetrate the 
vitelline membrane, and then dissolve in the vitellus. Yarious 
theories of penetration have been advanced. Barry, in 1840, 
thought he had discovered an opening in the zona pellucida of 
the rabbit, which appeared to be designed for passage of the 
spermatozoa. Kebler confirmed the discovery of such an open- 
ing, and called it the micropyle, and its existence is now gener- 
ally admitted in the instances of fishes, mo Husks, insects, etc. 
Robin* has made some very interesting and instructive observa- 
tions upon the ova of the nephelis vulgaris, or common leech. 
He found that the spermatozoa in their movements around the 
ovum assumed a perpendicular or oblique direction to the vitel- 
line membrane. At one point penetration of this membrane 
could be distinctly observed. At the end of an hour the pene- 
tration had ceased, and then a little bundle of spermatozoa could 
be seen arrested, partly within and partly without the ovum. 
They continued to move in the clear, limpid fluid surrounding 
the vitellus, for a time, but after fifteen or twenty minutes their 
movements grew slow, and in about two hours had altogether 
ceased. It was then found, by counting the number remaining, 
and comparing it with that of the spermatozoa which entered, that 
some had disappeared. They had been absorbed directly into 
the vitellus, to serve for its fecundation. 

Course of Spermatozoa to Point of Fecundation. — The 

movement of the spermatozoa through the uterus and Fallopian 
tube is probably effected by various agencies. First: By the 
undulatory motions of the spermatozoa themselves, although it 
is difficult to comprehend why these should propel them in any 

* " M^moire sur les Phenomenes qui se passent dans l'Ovule avant la segment- 
ation du Vitellus." Eobin, Jour, de la Physiol, t. v., p. 67. 



CHANGES IN THE OYUM AFTEB FECUNDATION. 89 

definite direction. Secondly: By the action of the cilise of the 
epithelium lining the passages. Thirdly: Muscular peristaltic 
contractions. It is highly improbable that their course is through 
the channel said, by Mauriceau, De Graaf, and others, to exist in 
the uterine walls. It is quite probable that such a canal exists 
only as an anomaly. 

Fig. 44. 




Bifurcation of tubal canal. — (Hennig. 

Changes in the Ovum After Fecundation.— It should be 
premised that our knowledge of what takes place in the ovum of 
the human female is derived mainly from analogy; but from the 
studies in comparative physiology diligently prosecuted by a 
few, it is quite probable that the changes described in the fol- 
lowing pages are worthy of credence. 

One of the earliest changes which has been observed is the 
disappearance of the germinal vesicle. This may occur, how- 
ever, whether fecundation has taken place or not, but, in an im- 
pregnated ovum, the embryo cell is formed in its place. Inas- 
much as the entire time consumed in the migration of the ovum 
to the uterine cavity is upwards of ten days, it is assumed that 
some of these changes take place while yet it occupies the outer 
third of the Fallopian tube. In this part of the tube the zona 
pellucida becomes somewhat thickened, the germinal spot dis- 
appears, and its place is supplied by the embryo* cell, while the 
vitellus becomes somewhat condensed. Before the egg enters 
the uterine cavity the more remarkable changes begin by seg- 
mentation, or cleavage of the yolk. Their first step is the forma- 
tion of a deep furrow, which, by extension, soon completely di- 
vides the yolk. These halves are likewise divided by a similar 



90 



THE PHYSIOLOGY OF THE OVUM. 



process, so that four spheres result. Nor does the segmentation 
stop here, but it goes on until the entire yolk has been converted 
into a finely granular mass, which has been well compared to a 
mulberry. It should be understood that this segmentation also 
includes the embryo cell or nucleus, so that every granular cell 
resulting from the subdivision has its nucleus. From this germ 
morula, or mass, the whole organization of the embryo is gradu- 
ally evolved. 

Now begins another important change. A clear fluid accumu- 
lates in the centre of the mass, and gradually increases in quan- 
tity, until finally a greater part of the original cells are flattened 



Fig. 45. 



Fig. 



Fig. 4T, 






m Successive stages of segmentation of the yolk. 

and closely crowded to the surface. We now have a vesicle, 
called the blastodermic vesicle, and the flattened cell wall is 
known as the blastodermic membrane. It is found now that by 
absorption, the dimensions of the ovum have been increased 
from a diameter of l-50th to l-25th of an inch. 

There are some of the cells, formed by the original segmenta- 
tion, which do not take part in the formation of the blastoder- 
mic membrane, and they accumulate and lie together at one spot 
just beneath the membrane. Then, by peripheral extension, 
these cells gradually spread over and line the inner surface of 
the blastodermic membrane, thereby giving to the ovum a second 
membrane. The outer layer of the blastodermic membrane is 
accordingly termed the ectoderm, and the inner layer the ento- 
derm. The zona pellucida is now called the chorion, and there 
is formed between it and the blastodermic membrane a thin 
layer of fluid. During the formation of the entoderm, a bright 
round spot is observed in the ectoderm, which, as further obser- 
vation shows, marks the place at which all the more important 
processes connected with embryonic development take place, 
and is termed the area germinativa. This is formed by the ag- 



CHANGES IN THE OVUM AFTER FECUNDATION. 



91 



Fig. 48. 



gregation of the original segmentary cells. It at first presents 
a homogeneous appearance, but it soon develops in its centre 
a clear space, called the area pellucida, bounded by a dense 
layer of cells. The area pellucida, at first circular, becomes 
oval, and there forms in its centre a dark oval spot, termed the 
embryonic spot. A longitudinal furrow, or shallow groove, then 
makes its appearance in the embryonic spot, which has been 
termed the primitive trace, the borders of which are called the 
dorsal plates. It constitutes the earliest indication of the cere- 
brospinal canal. 

A third intermediate cell-layer 
has meanwhile formed, termed 
the mesoderm, lying between the 
ectoderm and the entoderm. In 
this layer are developed the primi- 
tive blood-vessels, which, as they 
develop, give to the area germ- 
inativa the name of area vascu- 
losa. Later the mesoderm divides 
into two distinct layers, giving to 
the embryonic structures, at one 
stage, four distinct layers. 

Briefly it may be said that the 
ectoderm is concerned in the for- 
mation of the epidermis, hair, nails, the glandular structures 
of the skin, the brain, the spinal cord, the organs of special 
sense, and, it is supposed, in that of the genito-urinary system. 
The outer stratum of the mesoderm gives origin to the coruim, 
the muscles of the trunk concerned in moving the body, and the 
skeleton. The inner layer of the mesoderm provides the mus- 
cular and fibrous tissues of the digestive tract, the blood, the 
blood-vessels and the blood-glands. The entoderm supplies the 
epithelium lining the walls and glands of the intestines. 

When a transverse section of the primitive trace is placed 
under a microscope, its characters are readily recognized, while 
beneath the furrow a cylindrical organ known as the chorda do)'- 
salis, may be seen. It is about this structure that the vertebra^ 
eventually form. The latter bodies themselves are derived from 
two longitudinal chords, separated by a cleavage from the por- 
tions of the intermediate layer next to the chorda dorsalis on 




~~^2 

External surface of 
with area germinativa. 



the ovum, 



92 



DEVELOPMENT OF THE OYUM. 



either side. The peripheral portions of the mesoderm are now 
termed the lateral or abdominal plates. The dorsal plates con- 
tinue their development until they meet in the median line, 
forming a tube known as the tubus medullar is, the cavity within 
which is formed the central nervous system. 

The mesoderm, which at this point has been fused into a single 
layer, now separates into two strata, united by their inner bor- 
ders and thereby form what are known as the mesenteric folds. 
The opposite extremities of the inner stratum of the mesoderm 
curve inward, and finally unite to form the intestine, while at 
the same time, they inclose the entoderm. The closure in this 
case is from front to rear, as well as from side to side, but does 
not include the entire blastodermic vesicle, a considerable por- 
tion hanging during the early months to the body of the embryo, 
called the umbilical vesicle. Finally the ectoderm and the 
outer stratum of the mesoderm curve forward and inward to in- 
close a long cavity, which surrounds the intestines. This cavi- 
ty is eventually divided by the diaphragm into thorax . and ab- 
domen. 

no. 49. Flc :- 50 - 





a: a- 



The embryo as thus far formed gradually moves toward the 
center of the ovum, while there rises about it on every side, folds 
made up of the ectoderm and the outer layer of the mesoderm. 
Between the latter and the inner stratum, is a collection of fluid. 
The process of depression goes on, and the folds of the ecto- 
derm, now called the amniotic folds, approach closer and closer, 
until eventually they meet. The partitions are subsequently 
broken down, and there is formed a cavity, called the amniotic 



SOURCES OF NOURISHMENT. 



93 



cavity, with its outer sac termed the amnion. This cavity fills 
"with fluid known as the waters, or liquor amnii. 

Between the chorion and amnion is often found a gelatinous 
fluid, traversed by minute filamentous processes, called the viiri- 
form body, or corpus reticule. It sometimes exists in considera- 
ble quantity, and near the end of pregnancy may be discharged 
by rupture of the decidua and chorion, and give rise to the sup- 
position that the waters (liquor amnii) have escaped. 

Sources of Nourishment. — The ovum, during its passage 
through the Fallopian tube, is increased in size by absorption 
from 1-125 of an inch to from 1-50 to 1-25 of an inch. The 
structure previously alluded to as the umbilical vesicle is lined 
by the entoderm, and is covered by the inner stratum of the 
mesoderm. Its cavity, which at first communicates with the 
intestine, soon becomes separated by obliteration of its passage, 
but remains attached to the intestine by a pedicle. When once 
lodged within the cavity of the uterus, the ovum begins to draw 
its nourishment from the mucous membrane lining that organ, at 
first by mere absorption through its walls, and later through the 
utero-placental circulation. In order to obtain a clear idea of 
foetal nourishment, and hence of further embryonic development, 

Fig. 51. 




Human embryo at the third week, with villi of the chorion, 
it becomes necessary to enter into a more intimate acquaintance 
with certain structures to which allusion has already been made. 



94 DEVELOPMENT OF THE OYUM. 

The Chorion. — The chorion is the external membrane which 
envelops the ovum. Originally it consists, as stated elsewhere, 
of the vitelline membrane, or zona pellucida. Soon after the 
ovum enters the uterus this part develops amorphous villi, which 
serve to anchor the ovum to the uterine mucous membrane. 
When once the amnion has been formed by the meeting of the 
folds of the blastodermic membrane over the back of the em- 
bryo, and the absorption of the partitions between them, the 
outer layer of the blastoderm remains for a time in relation to 
the existing chorion; but the latter, so far as it is a vestage of 
the zona pellucida, disappears, and a new chorion, as it were, is 
formed from the ectoderm. The new chorion in turn becomes 
covered with a growth of non-vascular villosities, which are not 
solid, but hollow. These villi develop rapidly in size and num- 
ber, by a process of gemmation, so that at the close of the third 
week the entire OYum presents upon its outer surface its charac- 
teristic shaggy appearance. 

The Allantois. — During the third week a new organ is devel- 
oped, by means of which provision is made for supplying the 
rapidly increasing nutritive demands of the embryo. This organ, 
which establishes vascular connection between the embryo and 
chorion, is termed the allantois. It begins as a sac-like projec- 
tion from the posterior extremity of the intestine, while yet the 
umbilical vesicle is an organ of considerable size. It is com- 
posed of two layers derived from the entoderm, and the inner 
layer of the mesoderm, which soon unite to form one membrane. 
It at first is provided with two arteries and two veins, but later 
the vein on the right side becomes obliterated. These are the 
same vessels as are afterward found in the fully-developed um- 
bilical cord. Before the close of the fourth week the allantois 
reaches the chorion, and then begins to spread upon it and form 
a vascular lining. The chorion and allantois now become fused 
into a single membrane, and constitute the permanent chorion, 
the outer surface of which is called the exochorion, and the in- 
ner the endochorion. During the development of the allantois 
the umbilical vesicle diminishes rapidly in size, until at the end 
of the sixth week it is no larger than a pea. 

As development of the ovum advances, its surface becomes 
less and less vascular, except near the place where the allantois 






THE DECIDUA. 



95 



originally anchored to the chorion, and there vascularity is rap- 
idly increased. At other places the villi of the chorion also 
atrophy and disappear, until, after a time, the greater portion 
of the ovum becomes entirely free of villosities, while about one- 
third of its surface is covered with a thick, shaggy growth. This 
is the site upon which the placenta is ultimately formed. 

Fig. 




Formation of the Decidua Reflexa. (First Stage). 

The Decidua. — The decidua is composed of three distinct 
portions, namely: The decidua vera, the decidua reflexa, and 
the decidua serotina. The Decidua Vera is nothing more nor 
less than the mucous membrane lining the uterine cavity. The 
Decidua Reflexa is a structure formed from the uterine mucous 

Fig. 53. 




Formation of the Decidua Reflexa completed. 

membrane, which, when completed, closely envelops the ovum. 
Between these two portions there is at first, over a greater part 
of the surface, a decided interspace, filled with viscid, opaque 
mucus ; but after a certain degree of development has been at- 
tained, the enlarged ovum brings the two surfaces into close 
contact, and they soon become united. The Decidua Serofina 
is merely that part of the uterine mucous membrane on which 
the ovum rests, and which, eventually, is covered by the 
placenta. 

When first formed, the decidua vera is a hollow, triangular 
sac, having three openings into it, being those of the Fallopian 



96 



DEVELOPMENT OE THE OVUM. 



tubes and os uteri. It continues to develop, by hypertrophy, up 
to the third month, and then atrophy begins, and the process is 
continued until it becomes thin and transparent. When fully 
developed, it presents, under a lens, characters which clearly es- 
tablish its identity as hypertrophied uterine mucous membrane. 
The formation of the decidua renexa is an interesting study. As 
elsewhere remarked, the ovum, on reaching the uterine cavity, 
finds the mucous membrane in an hypertrophied and convoluted 
state, so that the cavity of the organ is well nigh obliterated. It 
therefore forms easy attachment in a fold near the point of en- 
trance, and the rapidly-formed villi of the zona pellucida serve 
to retain it. The mucous membrane at the base of the ovum be- 
gins to sprout about it, and extends until, after a time, the ovum 
is completely inclosed. Up to the third month, it should be re- 
membered, the decidua vera and decidua renexa are not in con- 
tact, since this fact has an important bearing on the question of 
Fig. 54. superfoetation. Near the 

close of pregnancy the decid- 
ua (both layers now forming 
cue membrane) becomes al- 
tered in appearance, and is 
fibrous and thin. Fatty de- 
generation sets in, its vessels 
and glands are obliterated, 
and it becomes easily separa- 
ble from the uterine walls. 

The Placenta.— The villi 
of the chorion are sent down 
into the tissues of the decidua, 
whence is derived the nutri- 
ment so necessary to proper 
development of the ovum. 
After the vascular relations between the embryo and perman- 
ent chorion have been formed, the area of nutritive supply is 
greatly diminished by atrophy of the villi of the chorion over 
about two-thirds of its surface, and the thinning, as well, 
of the decidua renexa, and obliteration of its vessels. As 
a result of these changes, the whole process of embryonic 
supply and waste becomes concentrated at the decidua sero- 
tina. The villi of the chorion at this point become arranged 




Flap of Decidua Renexa turned down 
disclosing the ovum. 



PLACENTAL VILLI. 



97 



in tufts, sixteen to twenty in number, the villi themselves multi- 
ply, and a thick, soft, spongy mass results, which constitutes the 
foetal portion of the placenta. Within the transparent walls of 
the villi the contained vessels may be seen under the micro- 
scope, distended with blood, and presenting an appearance 
somewhat resembling that of a loop of small intestine. 
These capillaries are the terminal ramifications of the um- 
bilical arteries and vein, with terminal loops contained in the 
digitations of the villi. From the accompanying cut it will be 

Fig. 55. 

t 




Placental Villus. 

seen that each arterial twig is accompanied by a corresponding 
venous branchy the two uniting to form the terminal arch or 
loop. By this means the blood of the foetus is brought very 
near the blood of the mother, but without coming into actual 
contact with it. This condition is verified by utter inability to 
force any fluid into the maternal circulation, by the most care- 
fully conducted injections through the foetal vessels. The exist- 
ence of lymphatics, or nerves, in the placenta, has never been 
demonstrated. 

The spaces between the villi of the placenta, which have been 



yo DEVELOPMENT OF THE OVUM. 

demonstrated to be sinuses in which circulates maternal blood, 
extend through the whole thickness of the organ, closely embrac- 
ing all the ramifications of the foetal tufts. The essential com- 
position of the placenta when fully developed is nothing but 
bloodvessels.* All the tissues which it originally contained have 
disappeared, save the bloodvessels of the foetus, associated with 
and adherent to the larger bloodvessels of the mother. 

General Description. — The placenta upon examination as a 
whole, is found to be a soft, spongy mass, of nearly a circular 
form. It measures about seven and a half inches in diameter, 
is about an inch in thickness at the insertion of the umbilical 

Fig. 56. 




Foetal surface of the placenta. 

cord, and has an average weight of about sixteen ounces. Its 
foetal surface is smooth, and, through the amnion which covers 
it, can be seen the vessels radiating in every direction over the 
surface of the organ. The uterine surface has a roughened, 
spongy feel, and is divided into a number of lobes, correspond- 
ing to the foetal tufts, or cotyledons, before described. The lat- 



*DALTON. " Treatise on Human Physiology," 1871, p. 646. 



THE PLACENTA. 



99 



ter are penetrated by curled arteries from the uterus, which 
convey the maternal blood into the lacunae or sinuses be- 
tween the foetal tufts. The blood returns to the uterus by the 
coronary vein on the margin of the placenta, and the sinuses in 
the septa between the cotyledons. 

Fig, 57. 




Uterine surface of the placenta. 

Functions. — "The placenta," says Dalton,* "must accord- 
ingly be regarded as an organ which performs, during intra- 
uterine life, offices similar to those of the lungs and the intes- 
tines after birth. It absorbs nourishment, renovates the blood, 
and discharges by exhalation various excrementitious matters 
which originate in the process of foetal nutrition." 

Abnormalities of form are often met. The organ is some- 
times divided into distinct parts ; while, again, smaller supple- 
mentary placentae, or placentce succeniurice, maybe found around 

* " Treatise on Human Physiology," 1871, p. 649. 



100 



DEVELOPMENT OF THE OVUM. 



the main mass. When this condition exists, one of the parts is 
liable to be left behind, exposing the woman to dangers of sep- 
tic infection and secondary hemorrhage. The umbilical cord, 
instead of being attached to the centre of the organ, may be at the 
margin, in which case it is termed battledore placenta. 

Fig. 58. 



v CK 



Clu \th 




IT AR.IAYER. 

Section of uterus and placenta in the fifth, month. Ch. chorion ; Am. amnion 
V. villi ; L. lacunar ; S. serotina; A E. areolar ; V. small arteries. — [Leopold:] 

The term insertio valamentosa is applied when the umbilical 
vessels extend for some distance through the membranes before 
reaching the placenta. 

Changes Preparatory to Separation. — These changes are of a 
degenerative nature, consisting chiefly in the deposit of calcare- 
ous matter on its uterine surface, and fatty degeneration of the 
villi and decidua serotina. Should these changes be either pre- 
mature or excessive, death of the foetus will be likely to ensue. 
The calcareous deposit is sometimes so marked that the uterine 
surface of the organ feels rough like a grater. 

The Umbilical Cord. — This is formed by elongation of the 
pedicle of the allantois, and obliteration of its cavity. When so 
constructed it consists of the following parts: the amniotic sheath 
which entirely surrounds it, except at one point, where a small 
slit gives egress to the pedicle of the shrunken umbilical vesicle; 



THE EMBRYO AND FCETUS. 101 

the two umbilical arteries, and one vein; the remains of the ped- 
icle of the umbilical vesicle; the remains of the pedicle of the 
allantois; and finally the gelatine of Wharton.* It is usually 
about the thickness of the little finger, but varies greatly, its 
circumference depending mainly on the quantity of Wharton's 
gelatine. Owing to the greater length of the right artery, the 
vessels in their spiral course generally observe the direction 
from right to left, the vein forming an axis about which the 
arteries curl. The average length of the cord is twenty-two 
inches, but it has been observed as short as three inches, and as 
long as five or six feet. The cord, as a rule, is possessed of con- 
siderable strength, as may be demonstrated by traction made 
upon it for the purpose of placental extraction. Still, in some 
cases, slight traction will cause it to part. One extremity is 
firnily attached to the umbilicus, and the other is woven into the 
tissues of the placenta. No nerves or lymphatics are said to 
exist in its structure. 

The Liquor Amnii. — The amniotic fluid is supposed to result 
mainly from the exudation of serum from a fine capillary net- 
work of bloodvessels developed just beneath the amnion, in that 
part of the chorion which covers the placenta. In the latter half 
of pregnancy this network of vessels disappears. The fluid is 
doubtless increased in quantity by urine, voided by the foetus 
during its intra-uterine existence. 



CHAPTEE II. 

Development of the Embryo and Foetus. 

An account of the development of the embryo and foetus be- 
longs properly to physiology, and allusion to it here is designedly 
brief. The term embryo is properly applied to the product of 
conception up to the close of the third month of utero-gestation, 
after which time the term foetus ought to be substituted. Em- 
bryology, save for the light which comparative physiology throws 
upon it, is, in the human, shrouded in much obscurity. The 
opportunities afforded for the examination of bodies, dead in the 
early stages of pregnancy, are very limited, and it is probable that 

* The only instance of mucoid tissue in a normal organ. 




102 DEVELOPMENT OF THE OVUM. 

our acquaintance with the subject must continue to be made 
mainly through study of the process in animals. 

fig. 59. In the First Month.— The 

embryo in the first month of 
gestation is a minute gelatinous 
and semi-transparent mass, of a 
grayish color, presenting to the 
unaided eye no definite traces 
of either head or extremities. 
The entire ovum measures but 
one-fourth of an inch, and the 
embryo one-twelfth. During 
the next week it doubles in di- 
mensions. The amnion is fully 
Ovum and Embryo. developed. Nourishment is de- 

rived from the umbilical vesicle. The allantois reaches the 
periphery of the ovum, but the vessels do not yet penetrate the 
villi. At the close of the month, the ovum is about the size of 
a pigeon's egg. It weighs about forty grains. The embryo is 
about three-fourths of an inch in extreme length, and about one- 
third inch in direct measurement. The ovum is so small that 
it readily escapes notice in abortions, generally passing with 
a coagulum. 

Second Month. — Ecker describes an embryo of eight weeks. 
It measured two-thirds of an inch in a direct line from the head 
to the caudal curve. The ovum itself was about the size of a 
hen's egg. The independent circulatory system of the embryo 
was beginning to form. The amnion was distended with fluid, 
and in contact with the chorion. The umbilical vessel was 
greatly reduced in size. Ossification had begun in the lower 
jaw, and the clavicle. 

Third Month. — The embryo weighs from 70 to 300 grains, and 
measures from 2^ to 3^ inches in length. The forearm is well 
formed, and the fingers are discernible. The head is relatively 
large, the neck separates it from the trunk, and the eyes are 
prominent. The chorion has lost most of its villi, and the pla- 
centa is formed. Points of ossification appear in most of the 
bones. Thin membranous nails appear on the fingers and toes. 
Fourth Month. — The foetus weighs five or six ounces, and is 
about six inches long. Its sex can now be determined. Distinct 



THE FCETUS. 



103 



movements are visible. The convolutions of the brain are be- 
ginning to form. Ossification is extending. The placenta is 
increased in size, and the cord is about twelve inches long. The 
head is one-fourth the length of the whole body. The sutures 
and fontanelles are widely separated. Hair begins to appear 
on the scalp. 

Fifth Month. — Foetal weight has increased to twelve ounces, 
and length to about ten inches. The head is still relatively large. 
Fine hair (lanugo) appears over the whole body. Foetal move- 
ments can be felt by the mother. 

Fig. 60. 




Ovum at five months. 

Sixth Month. — Weight about twenty-four ounces. Fat is 
found in the subcutaneous cellular tissue. .The testicles are 
still in the abdominal cavity. The clitoris is prominent. Hair 



104 DEVELOPMENT OE THE OVUM. 

is darker and more abundant. The membrana pupillaris exists, 
bnt the eyelids separate. If born at this time it breathes freely, 
but life is retained only a few hours, with few exceptions. 

Seventh Month. — Weight from three to four pounds; length 
fourteen or fifteen inches. The skin is wrinkled, of a red color, 
and covered with vernix caseosa. The testicles have descended 
into the scrotum. The foetus is now viable. 

Eighth Month. — Weight from four to five pounds; length 
sixteen to eighteen inches. Development is now rather in thick- 
ness than in length. The nails are nearly perfect. The mem- 
brana pupillaris has disappeared. The lanugo is disappearing 
from the face. The navel has gradually approached the centre 
of the body, until now it has nearly reached that median point. 

Ninth Months or At Term. — At the end of pregnancy the 
foetus weighs an average of six and a half or seven pounds, and 
measures about twenty inches in length. If we were to take the 
weights of children as given by mothers and friends, this aver- 
age would be greatly increased. Out of 3,000 children delivered 
under the care of Cazeaux, at different charities, but one reached 
ten pounds.* Of 4,000 children delivered at La Matefnite, one 
only weighed twelve pounds. (Lachapelle.) The birth of one 
has recently been recorded,f whose weight was twenty-one 
pounds. Probably the largest foetus on record was that born to 
Mrs. Captain Bates, the Nova Scotia giantess. It was born in 
Ohio, and its weight is said to have been nearly twenty-four 
pounds. Children have been born at maturity, and lived, whose 
weight was only one pound. The average weight of mature 
males is greater than that of females. 

At birth the foetus is covered with vernix caseosa, a whitish 
substance composed of a mixture of surface epithelium, down, 
and the products of the sebaceous glands. During intra-uterine 
life it serves as a protection for the skin against the amniotic 
fluid. It can be thoroughly removed only by preceding the use 
of water with a free inunction. 

Circulation of the Blood in the Foetus. — The following is a 
brief, but yet explicit, resume of. the foetal circulation. Blood is 
conveyed through the umbilical arteries, which are terminations,' 
or branches, of the iliac arteries, to the placenta, where, within 

* " Theoretical and Practical Midwifery," Am. Ed., 1878, p. 216. 
f Brit. Med. Jour., Feb. 1. 1879. 



THE FOETAL CIECULATION. 105 

the villi of the chorion, the interchanges with the maternal blood 
take place. After being thus renovated and recharged with oxy- 
gen, it collects within the umbilical vein from innumerable 
branches, and passes back through the umbilical cord to the 
liver. The blood thus returned to the foetus is, in a sense, arte- 
rial, and that which passed through the umbilical arteries, ven- 
ous; but it is in a modified sense only. After reaching the liver 
on its return from the placenta, a part of it circulates through 
the liver, while the rest passes through the ductus venosus into 
the inferior vena cava, and both these streams commingled con- 
tinue on to the right auricle. The two columns of blood — that is, 
the blood passing into the vena cava from the hepatic vein, and 
from the ductus venosus, join the stream which has been collected 
from the lower part of the body, and mix with it. In early foetal 
life the inferior vena cava opens at the septum of the auricles 
into both cavities, though the chief part of the blood enters the 
left, owing to increased development of the Eustachian valve. 
Subsequently this valve becomes smaller, and by the increased 
development of the valve guarding the foramen ovale, the cur- 
rent is turned more and more into the right auricle. In this 
cavity the blood is partly mixed with that which enters from the 
superior vena cava, and a part of it descends into the right ven- 
tricle, whence it passes, in part, through the pulmonary ar- 
tery into the lung tissue. No proper pulmonary circulation 
having yet been established, only about half the blood contained 
in the right ventricle enters the pulmonary artery, whilst the 
other half enters the descending aorta through the ductus arte- 
riosus. The imperfectly developed pulmonary veins convey to 
the left auricle but a small quantity of blood, the chief supply 
being received from the right auricle through the foramen ovale, 
through which passes the main stream from the inferior vena 
cava. From the left auricle the blood, which is semi-arterial, 
descends into the left ventricle, and thence into the first division 
of the aorta. By virtue of this movement the head and upper 
extremities are supplied through the carotid and subclavian ar- 
teries with the blood which has been but little deteriorated in 
quality, and escape the more venous current from the right ven- 
tricle through the ductus arteriosus. 

At the birth of the foetus there occurs a profound revolution 
in the circulation. Air now enters and expands the lungs, and, 



106 



DEVELOPMENT OF THE OVUM. 
Fig. 61. 




dl7&i2/& 



Diagram of the Foetal Circulation. 



THE FCETAL CKANIUM. 107 

as a result, blood begins to pass freely into the pulmonary cir- 
culation. The blood received into the right ventricle is now 
forced through the pulmonary system exclusively, the ductus 
arteriosus at once closing. After passing through the lungs and 
being oxygenated the blood flows in greatly increased quantity 
into the left auricle. It is presumed that in the latter cavity 
the blood pressure is considerably increased by cessation of the 
placental circulation, while, through moderation of relative sup- 
ply, the pressure in the right auricle is diminished, by means of 
which changes, the valve of the foramen ovale is enabled to close. 
As a result of these modifications, more especially in conse- 
quence of closure of the ductus arteriosus, the arterial pressure 
in the descending aorta is greatly diminished, and were the 
placenta left unseparated from the child, the long placental cir- 
culation could not be maintained. The blood still left in the 
cord soon coagulates, and circulation therein is effectually ar- 
rested. The ductus venosus also contracts on complete estab- 
lishment of the pulmonary circulation. The foramen ovale 
sometimes remains open for a short time; but, after its closure, 
owing to the peculiar construction of its valve, and the greater 
blood pressure in the left auricle, there is no intercommunica- 
tion between the blood of the two cavities. 

The Cranium. — The general anatomy of the foetal head is of 
much greater value to the obstetrician or student of midwifery, 
than that of any other part of the body. Apart from its dimen- 
sions, the chief anatomical peculiarity of interest is that of the 
cephalic bones, and more especially of the calvaria. These 
bones, are not firmly ossified at their contiguous margins in the 
foetus, but are joined loosely by membrane or cartilage, for- 
ming above by their united margins sutures, or commissures, 
and fonianelles. This arrangement permits the bones under 
forcible pressure to overlap, and the head thus to be moulded 
to correspond to the size and shape of the channel through 
which it has to pass. Since this change in form of the head 
affects only the vault of the cranium, the more delicate organs 
in the base of the brain are protected by unyielding osseous 
structures. 

An acquaintance with the characters of the foetal cranium is 
of the greatest service in furnishing the data from which to cal- 
culate the position occupied by the part as it presents in labor. 



108 DEVELOPMENT OF THE OVUM. 

The Sutures and Fontanelles. — The sagittal suture extends 
along the vertex, between the anterior and posterior fontanelles, 
and is formed by the junction of the two parietal bones. Run- 
ning forward in the same line, anteriorly .from the anterior fon- 
tanelle, is a short seam known as the frontal suture. The coro- 
nal suture is formed by junction of the edges of the two parietal 
bones and the frontal, and hence extends over the head in a lat- 
eral direction, constituting the anterior transverse suture of the 
vault of the cranium. The lambdoidal suture is the line of de- 
marcation between the occipital and two parietal bones, extend- 
ing transversely across the head, and forming a figure which re- 
sembles the Oreek letter \, from which its name is derived. In 
the other commissures of the foetal cranium we have no special 
obstetric interest. 

Ossification of the cranial bones at birth is incomplete, espec- 
ially at the margins which are thus approximated, and as the 
bones have only membranous, or, at the most, cartilaginous union, 
moulding of the head and overlapping of the bones, under the 
necessary compression, is generally accomplished by the natural 
efforts with facility, and thereby great mechanical advantage is 
gained. 

The corners, or angles, of the bones, as thus approximated, 
are obtuse, especially at the junction of the coronal, sagittal and 
frontal sutures, through deficiency of osseous structure, and 
hence there are gaps formed anteriorly and posteriorly, which 
are termed fontanelles. The largest of these is the anterior fon- 
tanelle, or bregma, which is formed by the concurrence of four 
seams, namely: the two branches of the coronal, the sagittal and 
the frontal, giving to the opening a lozenge shape. The larger 
part of the gap is in front of the direct line of the coronal suture, 
and is sometimes continued some distance into the frontal bone 
in the line of the frontal suture. The posterior fontanelle is very 
much smaller, and, in general, is hardly entitled to the designa- 
tion, since it would be scarcely possible to observe any pulsation 
there. Its shape is characteristic, and is rendered still more 
distinct during labor by depression of the occiput, whereby 
the limbs of the \ are made prominent. As will be noticed fur- 
ther on, the occiput, in the greater proportion of cases, is turned 
toward the pubis, and hence the posterior fontanelle is the one 
more easily felt by the finger in making an examination during 



THE FCETAL CEANIUM. 



109 



labor. Too much emphasis cannot well be put on its character- 
istics, namely its A shape, and the concurrence of only three 
commissures (the two branches of the lambdoidal and the sagit- 
tal). The anterior fontanelle is lozenge-shaped, and has four 
sutures concurrent, as stated; but what most markedly distin- 
guishes it during an examination, is the existence of the notch, 
more or less distinct, in the frontal bone. These characters will 
not at first be readily recognized by the student, but repeated 
examinations will render them familiar. 

Fig. 62. Fig. 63. 





The vertex. 



Posterior view of the cranium. 



Diameters of Foetal Cranium. — Familiarity with the relative 
diameters of the foetal head is essential to an intelligent practice 
of midwifery. Those of most importance are : 1. The occipito- 
mental, measurement being taken from the occipital protuberance 
to the point of the chin, the average giving five and one-half 
inches. 2. The occipitofrontal, from the occiput to the centre 
of the forehead, on a line with the frontal eminences, four and 
three-quarters inches. 3. The cervico-bregmatic, one pole being 
at the foramen magnum, and the other at the posterior margin 
of the anterior fontanelle, about three and one-half inches. 4. 
The bi-parietal, the two poles of the diameter being the parietal 
eminences, three and three-quarters inches. 5. The bi-temporal, 
being the measurement through the ears, three and one-half 
inches. 6. The fronto-mental, from the apex of the forehead to 
the chin, three and one-half inches. 7. The bi-malar, through 
the malar bones, three inches. 8. The sub-occipito-brcgmatic, 
one pole being say one-half an inch below the occipital protuber- 



110 



DEVELOPMENT OF THE OVUM. 



ance, and the other at the anterior fonfcanelle, three and one 
half inches. Others might be added, but those given comprise 
most of the diameters concerned in the mechanism of labor. 
Putting these figures in tabular form, they are as follows: 

Occipitomental 5 J inches 

Occipitofrontal 4f 

Cervico-bregniatic 3 J 

Sub-occipito-bregmatic 3 J 

Bi-parietal 3| 

Bi-Temporal 3 J 

Fronto-mental 3 J 

Bi-malar 3 

Without pausing now to di- 
late on the change of diameters 
which is effected in different pre- 
sentations and positions, it ought 
to be added that these averages 
were taken from heads which 
traversed the parturient canal 
in occipito-anterior positions 
of vertex presentations. Dr. 
Barnes * has shown by diagrams 
made from heads immediately 
after delivery, that, in difficult 
and protracted labor, the longer diameters may be increased 
more than an inch, as the result of lateral compression by which 
the bi-parietal diameter is reduced to correspond with the bi- 
temporal. 

Heads of Male and Female Children.— There are some gen- 
eral considerations in relation to the size of the foetal head which 
must not be overlooked. On taking the average measurements 
of a large number of male heads, and comparing them with those 
of an equal number of female heads, it becomes evident that the 
former exceed the latter. Sir Jas. Simpson f attributed to this 
fact the increased difficulties and dangers attendant on the birth 
of male children. This influence he believed to be so marked, 
that he made a careful estimate of the mothers and children lost 
in Great Britian during three years, as the result of slightly 

*Obstet. Trans, vol. vii. 

f Selected Obstet. Works, p. 363. 




Lateral view of bead, witb diameters. 



PRESENTATION AND POSITION. 



Ill 



increased cranial development in males, at about 46,000 infants 
and between 3,000 and 4,000 mothers. 

Attitude, Presentation and Position of the Foetus.— From 
the earliest period in pregnancy the foetus in the uterus con- 
forms itself to the shape of the organ, in the cavity of which it 
is placed. Its adaptation to a bent and flexed attitude is clearly 
disclosed early in embryonic life. While yet it floats freely in 
the liquor amnii, and is not at all pressed by the uterine walls, 
the correspondence of the embryonic with the f cetal ovoid is wor- 
thy of notice. The flexed attitude becomes more marked as preg- 
Fig. 65. nancy advances, and at the close of 

gestation the foetus is found with 
the spinal column bent forward, 
the chin on the chest, the arms flex- 
ed at the elbows and the forearms 
laid on the breast. The thighs are 
bent on the abdomen, the feet ex- 
tended so as to come in contact with 
the legs, and the latter, like the 
forearms, often crossed. This at- 
titude enables the foetus to occu- 
py the minimum amount of space, 
and gives to it the form of an ovoid, 
with the larger end represented by 
the head. 

Presentations and their Cau- 
ses. — The position of the foetus 
with respect to the direction of its 
long axis, constitutes what is known 
as presentation. When the ce- 
phalic pole of the longitudinal dia- 
meter is dependent, it is a cephalic 
presentation. When the knees, 
feet or breech lie over the os uteri, the pelvic pole of the 
long diameter presents, and hence it is called a pelvic pre- 
sentation. Finally, when neither pole of the long diameter 
presents, it is a transverse presentation. In more than nine 
mature cases out of ten the cephalic extremity forms the pre- 
sentation, and various theories have been advanced in explanation 
of the phenomenon. Notwithstanding the attention bestowed 




Attitude of the Foetus in Utero. 



112 DEVELOPMENT OF THE OVUM. 

on the subject, and the profound research to which it has given 
rise, the mystery remains but partially solved. It does not an- 
swer the claims of science to let the question rest merely on the 
plea of the suitability or desirability of such condition for the 
facile consummation of the reproductive process. Manifestly there 
is a cause, the influence of which is felt from an early period of 
foetal life, the ultimate effect of which is discovered in the won- 
derful adaptation of means to ends in the mechanism of labor. 
Hippocrates appears to have originated the idea that, until the 
seventh month of gestation, the foetus occupies a sitting posture, 
with the vertex turned to the fundus uteri, and that then a com- 
plete change of presentation is effected, as a preparation for ex- 
pulsion. The smaller percentage of cephalic presentations in 
miscarriages probably suggested this notion. Aristotle referred 
the frequency of head presentations to the laws of gravity, 
which is a theory still tenaciously held by some. To test this 
gravity doctrine, Dubois* experimented by suspending dead 
foetuses,, of different ages, in a vessel filled with water, and found 
that not the head, but the back or shoulder was the part which 
rested on the bottom. He accordingly denied the influence of 
gravity, and advanced the theory of instinctive or voluntary foe- 
tal movements to explain the phenomenon in question. Simp- 
son^ too, repudiated the theory, and substituted that of reflex 
foetal movements. Others have attributed the phenomenon to 
uterine contractions. Dr. Matthews Duncan has done more than 
any other recent observer to elucidate the subject. J In numer- 
ous experiments made by him, in which foetuses recently dead 
were allowed to float in a bag filled with salt water, of a specific 
gravity corresponding closely to that of the liquor amnii, it was 
seen that the head lay lower than the breech, and that the right 
shoulder (from the increased weight of that side due to the sit- 
uation of the liver) looked downwards. This appeared clearly 
to demonstrate that the centre of gravity lies nearer the cephal- 
ic than. the pelvic extremity. "The position (presentation) of 
the foetus at the full time is," says Dr. Duncan, " in the great 

* Dubois. " Memoire sur la cause des presentations de la tete." Mem, de 
l'Acad . Roy. de Med. tome ii. 1833, p. 265. 
t Simpson. " Obstetric Works," vol. ii, p. 81. 
$"Obstet. Researches," p. 14. 



PRESENTATION AND POSITION. 113 

mass of cases, fixed and determined about the end of the seventh 
month of pregnancy. This arises from the fact that about that 
time the size and shape of the uterus become so nearly and 
closely adapted to the size and form of the foetus, that it cannot 
change the position of its trunk in any material degree. After 
this time the position of the foetus must be determined by grav- 
tation, for it is impossible to conceive its reposing in any other. 
"All the knowledge we possess of the position (presentation) 
of the foetus, after it has entered the second half of pregnancy, 
leads us to believe that its head lies ordinarily lowest. Before 
the seventh month it is still capable of having its position in 
utero changed, by changes merely in tho attitude of the mother, 
and probably it possesses the power of effecting temporary changes 
at least, by its own unaided movements. But the foetus is gen- 
erally in a state of repose, and not producing motions in its 
limbs or body. In this state of repose, in a fluid of nearly its 
own specific gravity it is impossible to conceive of its maintain- 
ing any position but under the influence of gravity. Its position 
must at all times be mainly, if not entirely, caused and deter- 
mined by statical circumstances. It is quite conceivable, that 
while still comparatively free in the uterus, it may, by virtue of 
its very easy mobility in the dense liquor ammi, change its posi- 
tion. If this occur at a time when its dimensions are beginning 
to approximate to those of the uterus, having overcome some 
resistence of the uterine walls by the force of its own muscular 
efforts, or otherwise — as by accidents to the mother — it may not 
gravitate back to its old and ordinary position, and thus a pre- 
ternatural presentation may be produced. The uterine walls are 
everywhere smooth and glabrous, and rounded; and the foetus 
lies in its cavity with its legs, its chief organs of locomotion, 
elevated; circumstances which appear to render its maintenance 
of any position but that of gravitation a greater feat than ever 
was performed by a rope dancer. With all the advantages of 
its new circumstances, the child after birth cannot assume or 
maintain a new position. How much less could it be expected 
to do so in the uterus, and under circumstances so disadvantage- 
ous for the fulfillment of such a function. Those authors who* 
with Dubois, strive to prove that the position of the foetus is 
determined by its own motions, have first to prove that it could 
maintain any position whatever against gravity, without such 



114 



DEVELOPMENT OF THE OVUM. 



constant efforts as voluntary muscles are incapable of, and of 
the actual presence of which no evidence can be furnished." 

Without entering further into a consideration of this question, 
it may be added that cephalic presentation of the foetus is not 
probably referable wholly to any one cause, but a combination of. 
causes, in which gravitation, uterine contractions, and reflex 
movements all have an influence. 

Position. — By this term we design to signify the relation of 
certain determinate points in the body of the foetus to the uter- 
ine walls. Care must be taken not to confound the two terms — 
presentation and position. To simplify an understanding of the 
Fig 66. various positions, we shall re- 

gard the dorsal surface of the 
foetus as the cardinal feature 
from the direction of which to 
designate positions. And still 
it will be observed, when this 
subject is treated at length, that 
positions are often designated 
by the direction of the occiput 
in vertex presentation, and the 
chin in face presentation, as, for 
example, right occipito-anterior 
position, left mento-posterior 
position, and so on. Full con- 
sideration of this subject will 
be taken up in another chapter. 
Changes of position are fre- 
quent in pregnancy, and, very 
likely, like presentations, take place, when not subjected to con- 
trary influences, in a large measure through obedience to laws of 
gravity. This is not mere speculation, for close observation has 
substantiated its truth. When the woman is in the erect posture, 
the axis of the uterus is presumed to correspond closely with the 
axis of the plane of the superior strait, and hence forms with the 
horizon an angle of about thirty degrees. There is generally a 
little deviation to the right. It is also slightly twisted, so that 
its left lateral surface looks somewhat forward. Therefore, when 
the woman is erect, the anterior uterine wall is not only inclined 
at the angle mentioned, but the left side drops a little lower than 




Situation and surroundings of the 
foetus in utero. 



PRESENTATION AND POSITION. 115 

the right. If these facts receive attention, we will readily dis- 
cover that when the child rests on the incline, with the head de- 
pendent, that the heaviest part of the body will gravitate to the 
lowest surface, and hence we most frequently get a position with 
the back turned to the left, and somewhat forward, and, for mani- 
fest reasons, this is more likely to be true in the uterus that has 
previously experienced the distension of pregnancy. 

With the woman in the dorsal decubitus the long uterine axis 
is still at an angle with the horizon, and the child's weight is 
thrown on the posterior wall of the uterus, upon which the 
heaviest part of the superior portion of the body would naturally 
seek the lowermost surface, and would accordingly be directed 
to the assumption of a right dorso-posterior position. 

These are practical considerations, and well worthy the stu- 
dent's thoughtful attention. 

Diagnosis of Fcetal Presentations and Positions. — It is 

highly important to know, as early as possible after labor 
sets in, the presentation and position of the foetus. If the pre- 
senting part has been driven downward into the pelvic cavity, 
and the membranes have ruptured, this can usually be learned 
without much difficulty by a vaginal examination. But if de- 
scent of the presenting part has not yet been accomplished; if 
there is a tense and full bag of waters, and if the os uteri is but 
partially dilated, and is reached with difficulty, such diagnosis 
is not easily made in every instance, even by experts. In a case 
of this kind it will be necessary to bring to our aid the informa- 
tion derivable from external examination. 

Examination Through the Y agina,— In the vast majority of 
cases positive information can be gained from vaginal explora- 
tion alone; but in some instances its revelations, as ordinarily ob- 
tained, are most unsatisfactory. One not thoroughly familiar 
with the feel of the characters of the various presenting surfaces, 
will do well to verify conclusions by external means. 

The head is recognized from its shape and hardness, which 
differ from those of any other presenting part. To the inexpe- 
rienced these may not be wholly characteristic, for students and 
young practitioners have often mistaken the head for the breech; 
and the breech for the head. The breech, when fairly crowded 
into the pelvic brim, or cavity, does give out a feeling of resist- 



116 DEVELOPMENT OF THE OVUM. 

ance, which, to a casual examiner, is liable to prove deceptive. 
An attentive observer will rarely, or never, be misled. But these 
remarks do not apply with equal force to both varieties of ce- 
phalic presentation, since the vertex possesses characters not as- 
sociated with the face. The vertex will be distinguished mainly 
by its sutures and fontanelles. As the finger is passed through 
the os uteri and rests upon a fontanelle, it is most frequently the 
posterior, and it will be recognized by its ^ shape, which is gen- 
erally easily felt. From the apex of this figure, the finger passes 
along the sagittal suture to its extremity, where the anterior fon- 
tanelle will, be found. The face will be recognized from the feel 
of mouth, nose, chin and eyes, though these features will be con- 
siderably obscured by the pressure to which the part is sub- 
jected, and the consequent tumefaction. Such presentation is 
more likely to be confounded with breech presentation than any 
other, and differentiation must be made by a detailed study of the 
parts, as the fingers are swept over them. 

When the pelvic end of the foetus is turned to the os uteri the 
feet or knees may be in advance, or, what is more frequent, the 
breech presents. 

The characters of this part can scarcely be mistaken. At first 
one natis only is found, but, when the os uteri opens, the other 
is felt, and the cleft between the two. The genitals, the point of 
the coccyx, the anus, and the rudimentary spines of the sacrum, 
pass under inspection, uniting to declare the character of the 
presentation. 

In transverse presentation, the precise surface upon which the 
examining finger falls can generally be made out, though not al- 
ways with facility. The side would be recognized from feeling 
the ribs, and the shoulder would be distinguished by the scapula, 
the vertebrae, and its own peculiar contour. In early examina- 
tion the presenting part may lie entirely out of reach. This is a 
diagnostic fact of much value. 

Upon examining per vaginam in these cases, we find, when 
the feet or knees present, that, early in labor, diagnosis is many 
times a matter of some difficulty, inasmuch as an extremity is 
felt, but it moves before the finger, and will not admit of careful 
study. Later, however, it comes within reach, sometimes sud- 
denly, by rupture of the membranes, and escape of the liquor 
amnii. The foot would be distinguished mainly by the toes and 



PKESENTATTON AND POSITION. 



117 



heel, and the knees would be known from their size, and the ob- 
tuseness of their points. 

When the presentation is either transverse or pelvic, the bag 
of waters is generally larger and longer, and may render thor- 
ough exploration unusually difficult. In vertex presentation, 
when the bag is large and tense, its feel is liable to mislead the 
inexperienced to suppose the breech or the face is presenting. 

Fig. 67. 




Diagnosis of Presentation and Position by Abdominal 
Palpation. — This subject has received considerable attention of 
late, and its value during pregnancy, for the purpose of diagnosis, 
has been clearly demonstrated. Dr. Paul F. Munde * has fur- 
nished a most interesting and valuable paper on the subject, with 
some very excellent illustrations. Dr. Depaulf has likewise 
given some important instruction concerning its value and meth- 
ods, with figures 

According to the writers mentioned, and others, a little prac- 
tice will enable one to elicit by means of abdominal palpation, 
most valuable information concerning both the presentation and 



* Am. Jour. Obs., vol. xii, p. 512, etc. 

f " Lecons de clinique Obstetricale." 1872-1876, p. 21. 



118 



DEVELOPMENT OF THE OVUM. 



position of the foetus. Examination ought first to be with ref- 
erence to the direction of the long uterine axis. If that corres- 
ponds pretty closely to the longitudinal axis of the woman's body, 
the presentation must be either cephalic or pelvic. By spreading 
the hands over the uterus, a greater sense of resistance and f ul- 

Fig. 68. 




ness can generally be felt more to one side or the other, which 
represents the situation of the foetal back. Now, by deep palpa- 

Fig. 69. 




tion with a single hand on the hypogastrium, the head of 
foetus, if presenting, can be felt, and recognized by its form 



the 
and 



PRESENTATION AND POSITION. 



119 



Fig. 70. 



hardness. By striking the tips of the fingers suddenly inwards 
at the fundus, the hard breech can generally be made out, or the 
head, if there, still more easily. It is also possible, as a rule, 
to feel the foetal limbs, especially on provoking movements. 
When the foetus lies in a transverse presentation, diagnosis is 
still less difficult. The long foetal axis being thrown across the 
abdomen, gives to the part a feel wholly different from that found 
in connection with other presentations. The rounded mass of 
the head can be easily felt in one iliac fossa or the other, or at a 
point still above. 

Diagnosis of Presentation and 
Position by Abdominal Anscnl- 
tation. — This is another means of 
diagnosis not properly valued or 
understood by obstetric practition- 
ers. For general purposes the un- 
aided ear will answer very well; 
but for the diagnosis of presen- 
tation and position, the stetho- 
scope is a necessity, as without it 
the summum of intensity of the 
sounds cannot be circumscribed. 
The most common location of the 
foetal heart sounds is on the left 
side below the umbilicus : 1. Be- 
cause the back of the child is most 
frequently turned toward the moth- 
er's left, and 2. Because the head 
generally presents, at the os uteri. 
The first fact, then, to be kept in 
mind is that when the foetal back 
is turned toward the left side of 
the mother, the heart- sounds will 
be most distinctly audible on that side. The just inference 
to be taken from this is not that the position is neces- 
sarily a left dorso-anterior one, though it is more likely to be. 
It may be a left dorso-posterior position, with but a moderate 
inclination backwards. Accordingly we conclude that when the 
sounds of the foetal heart are most distinct on the mother's left 
side, the position is either a left dorso-anterior, or a left dorso- 




Showing at + the locations 
the fcetal heart-sounds. 



of 



120 



DEVELOPMENT OF THE OVUM. 



posterior position; in other words, it is a first or a fourth posi- 
tion, with the probabilities strongly in favor of the former. If 
Fig. 71. Fro. 72. Fig. 73. 





Location of the 
heart sounds, 
first position of 
the vertex, at-f- 



First position of 
the face. Loca- 
tion of heart- 
sounds indicated 




First position of the 
breech. Location 
of heart-sounds in- 
dicated by -{-. 



heard most clearly at a point an inch or more below the line 
of the umbilicus, the woman being near term, it is a cephalic 

Fig. 75. 




Dorso-anterior posi- 
tion of transverse pre- 
sentation. Location 
of heart-sounds indi- 
cated by +• 




Twin pregnancy. Lo- 
cation of heart-sounds 
indicated by -f- 



presentation; if heard most distinctly at a point as high as the 
umbilicus, or higher, it is a breech presentation. When the sum- 



DIAGNOSIS OF TWIN PREGNANCY. 121 

mum of intensity of the foetal heart-beat is on the right side, 
the position is either right dorso-anterior, or right dorso-pos- 
terior; or, in other words, it is either a second or a third po- 
sition, without regard to the presentation. But now, if the 
point of strongest audibility is on or below a line drawn trans- 
versly across the abdomen about an inch below the umbilicus, 
the woman being near term, it is almost certainly a cephalic pre- 
sentation. If the sounds are most distinctly audible at a point 
above the umbilicus, the presentation is almost certainly pelvic. 
In transverse presentation the foetal heart is heard most forci- 
bly on or near the median line of the abdomen, several inches 
below the umbilicus. 

Diagnosis of Twin Pregnancy, from Auscultation. — In 

twin pregnancy the foetuses lie upon either side of the abdomen, 
and from mere inspection a diagnosis can sometimes be made. 
The stethoscope will be applied to one side, perhaps the left, 
below the umbilicus, and the sounds there heard counted by the 
watch. The investigation is still further pursued, and on the 
opposite side of the abdomen, perhaps on a line with the first 
sounds, but more likely at a higher point, a foetal heart of a 
different rhythm is heard, and its pulsations counted. From 
such an examination it becomes clear that there are two foetuses 
in utero, and furthermore that their positions, and perhaps their 
presentations, vary. The same principles of diagnosis of pre- 
seniaiion and position are here involved as in the instance of 
single pregnancy. In the same connection it should be borne in 
mind that the dorsal surfaces in twin pregnancy, and the cephal- 
ic extremities, are, as a rule, turned in opposite directions. 
That is to say, the back of one foetus generally looks toward the 
mother's left, and that of the other toward her right; while the 
head of one foetus is usually turned toward the os uteri, and that 
of the other toward the fundus. 

These ideas of presentation and position derivable from pal- 
pation and auscultation, are not theoretical merely, but highly 
practical, as the author has demonstrated in hundredsof cases 
within the Obstetrical Department of Hahnemann Hospital, 
Chicago, as well as in private practice. 

Diagnosis of Sex from Rapidity of the Fcetal Heart. — The 

possibility of determining with tolerable accuracy the sex of the 



122 DEVELOPMENT OF THE OVUM. 

foetus in utero from the rapidity of the heart's action, has com- 
manded the confidence of some, and is deserving of study. The 
theory is founded on the clinical observation that the heart of 
the female foetus exceeds in rapidity of pulsation that of the 
male. That there is an element of truth in the theory, is plainly 
shown by the reports of all who have given the matter attention, 
but experience of different observers, has, nevertheless, been far 
from uniform. Steinbach was correct in forty-five out of fifty- 
seven cases which he examined, and Frankenhaeuser * made not 
a single mistake in fifty consecutive cases. But other careful 
observers fall far short of such marvellous success. 

In studying the subject, one should not forget the influence of 
both maternal and foetal states upon the heart's action. It is 
probably as true of intra, as of extra-uterine life, that such in- 
fluences much more frequently accelerate, than retard, the car- 
diac contractions, and hence we often find the male heart simu- 
lating, in point of rapidity, the female heart. This affords a 
rational explanation of the greater relative frequency of males 
when the pulsations fall below 135J to the minute, than of fe- 
males when the pulsations exceed that number. That disturb- 
ance of the vital force of the foetus, and its reduction to a low 
ebb, is exhibited in the pulsations, is clearly shown in observa- 
tions carefully conducted. An instance of the kind appears in 
the succeeding tables. The mother was in very feeble health, 
and, two months prior to delivery, the heart of a male foetus 
which she bore was pulsating so rapidly that it could scarcely 
be followed — 172 times a minute. The child was still-born, near 
term, and presented evidence of life having been extinct for sev- 
eral days. 

The author's personal observations in ninety-six unselected 
cases gave an average pulsation of 135|. The results of observa- 
tions, with this as the intermediate point in the scale, is given in 
the accompanying table : 

Male. Female. 

Pulsations in excess of 135| 25 24 

Pulsations below 135 J 35 12 

Total 60 36 

Average pulsations of males 134 

Average pulsations of females 138 

* " Monatssehr, f. Geburtsk.," Bd. xiv, p. 161. 



DIAGNOSIS OF SEX FROM HEART-SOUNDS. 123 

According to these figures, it will be observed that if diagnosis 
of sex had been made in accordance with the theory of cardiac 
rapidity alone, they would have been correct in only fifty-nine 
out of ninety-six cases, or, in but little more than sixty-one per 
cent, of them. 

As the proportion of males in these ninety-six cases is so far 
in excess of females, it appears that a comparative statement, 
constituting in some regards a more equitable showing, should 
be based on an equal number of males and females. In order to 
present such a table, we have taken the entire number of females 
(36), and compared it with a like number of males taken in regu- 
lar order from the records, first in chronological order, and 
secondly in reverse order, with the following results : 

Comparative Statement of the Fcetal Heart-Sounds in 
Thirty-Six Males, Taken in Chronological Order from 
the Author's Kecords, and Those of the Entire Thirty- 
Six Females in the Foregoing List : 

Cases wherein the pulsations exceeded the 

average number of 135 J per minute : 

Males, 14 — about 37 per cent. 
Females, 24 — about 63 per cent. 
Cases wherein the pulsations fell below the 

average number of 135J per minute : 

Males, 22 — about 65 per cent. 
Females, 12 — about 35 per cent. 

A Comparative Statement, Similar to the Foregoing, the 
Thirty-Six Males Being Taken from the Eecords in Ke- 
verse Chronological Order : 

Cases wherein the pulsations exceeded the 

average number of 135 J per minute : 

Males, 13 — about 34 per cent. 
Females, 25 — about 66 per cent. 
Cases wherein the pulsations fell below the 

average number of 135 J per minute : 

Males, 23 — about 68 per cent. 
Females. 11 — about 32 per cent. 

These observations were made in hospital practice, and the 
unusual proportion of male children is not easily explained on 
any other basis than the recognized preponderance of that sex 
among the illegitimate : 



i 



124 



DEVELOPMENT OF THE OVUM. 



Pulsations of Fcetal Heart. Male. Female. 

110 1 

116 1 

120 2 

122 4 

124 : 1 1 

126 5 1 

128 3 2 

130 10 1 

132 5 3 

134 5 2 

136 2 3 

138 4 2 

140 9 6 

142 5 5 

144 2 

146 1 1 

148 4 

150 1 

160 1 

162 1 1 

172* 1 

Totals. 60 36 



er's Age. Av 


erage Pulsations. 


Male 


Female 


14 


120 


.. 


1 


16 


141 


.. 1 


2 


17 


136 


.. 3 


2 


18 . 


. 137.. 


1 


2 


19 


135 


.. 4 


3 


20 


138 


.. 6 


4 


21 


137 


.. 8 


5 


22 


....132 


..13 


2 


23 


145f 


.. 5 


1 


24 


137 


.. 5 


2 


25 


130 


.. 2 


1 


26 


144 


.. 1 


1 


27 


126 


.. 2 





28 


136 


.. 1 


2 


29 


123 


.. 3 





30 


134 


.. 2 


5 


32 


136 


.. 1 





34 


136 


.. 1 





35 


142 


.. 


1 


37 


160 


.. 


2 


38 


132 


.. 1 





Totals 




..60 


36 



* Case of dying foetus before mentioned. 
f Dying foetus raised the average. 



CHANGES BESULTING FKOM PREGNANCY. 125 



CHAPTEE III. 

The Changes in the Maternal Organism that are 
Wrought by Pregnancy. 

Following closely on the heels of impregnation, changes are 
begun in the maternal organism, a knowledge of which is essen- 
tial to an intelligent view of the subject of utero-gestation, and 
the skillful performance of obstetric duties. 

Uterine Changes. — Impregnation is followed by increased 
vascularity of the uterus. The mucous membrane becomes thick- 
ened and convoluted, and there is begun the formation of the 
important structures known as the deciduse. The textural 
changes are both numerous and great. New muscular fibres 
form. The connective tissue processes, between the muscular 
fibres, become more abundant. The arteries assume a spiral 
course, and increase both in number and size, while the veins di- 
late and form wide-meshed reticulated anastomoses. The veins 
when examined seem to be mere canals of considerable size, 
coursing through the uterine muscular tissues, particularly in 
the vicinity of the placenta. The lymphatics form numerous 
plexuses in various parts, but especially at the fundus. The 
nerves lengthen and thicken, and stretch inward to the cavity of 
the organ, on the surface of which ganglia are formed. 

The general changes are equally well marked. The unimpreg- 
nated uterus measures two and a half to three inches in length, 
and weighs little more than an ounce. From these dimensions 
the organ comes to weigh at the close of gestation twenty-four 
ounces, and to measure about twelve inches. Uterine growth 
may be said to begin coincidently with development of the ovum, 
and continue without interruption to the close of pregnancy. 



126 CHANGES RESULTING FROM PREGNANCY. 

Farre has furnished the following table of approximate uterine 
dimensions for the several calendar months of utero-gestation: 

Length. Width. 

End of third month 4| — 5 inches. 4 inches. 

End of fourth month 5| — 6 inches. 5 inches. 

End of fifth month 6 —7 inches. 5} inches. 

End of sixth month 8 — 9 inches. 6 J inches. 

End of seventh month 10 inches. 7 J inches. 

End of eighth month 11 inches. 8 inches. 

End of ninth month 12 inches. 9 inches. 

According to Levret's figures,* the virgin uterus presents a 
surface of sixteen square inches, and the pregnant uterus at term 
measures 339 square inches. Krause f says the uterine cavity 
is enlarged by pregnancy 519 times. 

The uterus in the early part of pregnancy is not enlarged from 
centrifugal pressure exerted by the expanding ovum, as is shown 
by similar development taking place, even in extra-uterine preg- 
nancy. In the latter months, the expansion is in great measure 
mechanical. The walls become thinned, and their thickness 
varies from one-sixth to one-fourth of an inch. The muscular 
layers become developed to a surprising degree, and are clearly 
discernible. They are three in number : 1. The external layer 
is thin and delicate, and is adherent to the peritoneum. 2. The 
intermediate layer, heavy and strong, composes the greater thick- 
ness of the uterine walls. This is made up of fibres that sur- 
round the vessels, and interlacing circular and longitudinal fibres. 
3. The inner layer, a frail structure, formed mainly of circular 
fibres, surrounds the orifices of the Fallopian tubes and the os 
uteri internum. 

As the uterus increases its dimensions, its serous covering is 
put upon the stretch, and, with the advance of pregnancy, the 
layers of the broad ligament separate, until finally the Fallopian 
tubes and ovaries lie in contact with the uterus. 

In the early months, while yet the uterus is a pelvic organ, the 
increase is rather in breadth and thickness than in length, so 
that it is more spherical than in a non-pregnant state. After it 
leaves the pelvic cavity, development of the organ is more in a 
longitudinal direction, so that it comes to assume an ovoid shape, 

* Scanzoni, " Handhuch der Gehurtschiilfe," p. 77. 
t Spiegelberg, " Handbuch der Gehurtschiilfe," p. 51. 



UTERINE CHANGES. 127 

with the narrower extremity below, at the cervix and os. In the 
fifth month, the uterus fills the hypogastrium, and in the ninth 
month its fundus reaches the epigastrium. 

Change in Situation. — The first change is in a downward 
direction, as a result of which, from its close anatomical relations 
to the bladder, and the connection, in turn, of the bladder to the 
umbilicus by means of the urachus, fchere is abdominal flattening 
and umbilical retraction. It is only after the gravid organ rises, 
so that its bulk is above the pelvic brim, that abdominal increase 
is observable. This change in situation, which takes place at 
the close of the third or beginning of the fourth month, is gen- 
erally a slow one, and, when completed, enables us to feel the 
form of the organ in the hypogastrium. 

A few days before the advent of labor there is a slight subsi- 
dence, or downward movement of the uterus, very marked in 
some women, but scarcely noticeable in others. The cause of it 
is to be found chiefly in the extreme relaxation of the soft parts 
which precedes delivery. 

The Inclination of its Longitudinal Axis. — The fully de- 
veloped gravid uterus lies within the abdominal cavity, its cervix 
directed downward and backward, and its fundus upward and 
forward. There is also, in general, a slight lateral obliquity, the 
inclination most frequently being toward the right. Situated 
thus, its anterior surface rests against the abdominal parietes, 
its long axis nearly parallel with the axis of the plane of the 
pelvic brim, thereby forming with the horizon an angle of about 
thirty degrees. It assumes the vertical line only when the woman 
is in the semi-recumbent posture. From excessive relaxation of 
the abdominal parietes, a pendulous condition sometimes exists. 

Changes of Cervical Position.— The situation of the cervix 
must obviously depend largely upon the situation and inclination 
of the uterine body. Hence, in the early weeks of pregnancy, 
the cervix is within easy reach of the finger. After the third 
month it is higher, and situated so far posteriorly as sometimes 
to place it almost beyond reach of the index and middle fingers. 

Changes in the Size and Texture of the Cervix Uteri. — 
The cervix shares in the hypertrophy of the body and fundus of 
the uterus, but this change is generally completed by the fourth 
month. The increase in size is partly from an increased growth 
and new formation of tissue elements, but more especially from 



128 



CHANGES RESULTING FKOM PREGNANCY. 




Cervix uteri at the end of third month 



the loosening of its structure and distension of its tissues from 
serous infiltration. The cervical vessels, under the stimulus of 
the process going on in the uterine cavity, are dilated, and the 

result is hyperemia of the part, 
and consequent oedema. These 
conditions in turn occasion a 
physiological softening of the 
tissues, first manifested in those 
parts where there is least resist- 
ance, that is, under the mucous 
membrane on the lips of the os 
externum, and from this point 
continued progressively upward 
toward the os internum. The 
cervical follicles are active, and 
pour out their secretions, though 
the formation of a "mucus plug," described by some authors, 
is questionable. The orifices of these follicles are liable to occlu- 
sion, in which case little sacs are formed, known as the ovules 
of Naboth. 

Most of the standard works on midwifery allude to a progress- 
ive shortening of the cer- fig 
vix uteri which is supposed 
to take place in pregnancy. 
Stoltz, in 1826, questioned 
the truth of this theory, but, 
according to Dr. Duncan, 
he was preceded by Weit- 
brech in 1750. Various 
post-mortem examinations 
by others have clearly 
shown that, contrary to the 
older teachings, the cervix 
does not lose half its length 
by the sixth month, two- 
thirds of it by the seventh, 
and all of it by the middle 
of the eighth. To be sure, 
the part does not present 
the prominence which it once possessed, but the change is in 




Cervix uteri at beginning of fifth month. 



UTERINE CHANGES. 



129 



the direction of softening and elevation without coincident 
shortening or obliteration of the cervical canal by expansion 
of the internal os uteri. We have insisted on the truth of this 
for years, as the result of careful examinations, and we are con- 
vinced that, in the majority of cases, the internal os uteri does 
not yield till labor supervenes, or is near. According to Dr. 

Fig. 78. 




Showing the bulging of the anterior uterine wall from pressure 
of the foetal head. 

Matthews Duncan, the change occurs during the latter half of 
the ninth month, but, even then, the obliteration of the cervical 
canal appears to be due to the incipient uterine contractions 
which prepare the cervix for labor. " The length," says Dun- 
can, " of the vaginal portion of the cervix, or the amount of pro- 
jection into the vaginal cavity, greatly diminishes as the uterus 
rises into the cavity of the abdomen." 

This is far from being a constant phenomenon of pregnancy, and 



130 



CHANGES KESULTING FKOM PKEGNANCY. 



yet it is probably one of the causes of the mistaken ideas for- 
merly entertained regarding cervical shortening. On making an 
examination, the vaginal portion of the cervix is f onnd not to be 

as prominent as usual, and, in- 
deed, in some cases, even scarcely 
to be felt, and the inference has 
generally been that the cervical 
body has been annihilated. The 
opposite result, as is well known, 
is produced by depression of the 
uterus, as in the early weeks of 
pregnancy. This change has 
led Boivin and Filugelli to re- 
Cervix uteri at end of eighth month. gar( j the cervix as lengthened. 

It is probably true, however, that to actual measurement there 
is a certain amount of cervical shortening, which takes place dur- 
ing pregnancy, growing out of the physiological softening which 
occurs; but it is not a shortening consequent on relaxation of the 

Fig. 80. 





Cervix of a woman who died in the eighth month of pregnancy. (After 

Duncan). 

internal os, and infringement upon the cervical canal, as has been 
supposed. Post-mortem, and careful vaginal examinations, have 



UTERINE CHANGES. 131 

clearly shown that the internal os uteri does not expand until 
near the close of utero-gestation. 

Another factor in the production of apparent shortening is 
probably the bulging of the uterine wall anteriorly to the cervix, 
as an effect of downward pressure of the presenting head. This 
condition, which, while common, though by no means uniform, 
causes the os uteri to be directed backward toward the sacrum, and 
gives rise at times, especially in late pregnancy, to considerable 
difficulty in reaching the part, and at the same time produces a 
marked shortening of the anterior lip of the os uteri. By push- 
ing the head upward, or by placing the woman on her knees and 
elbows, so that the head will recede, the cervix is made to resume 
its normal situation and feel. 

As pregnancy advances 
the os uteri becomes more 
and more patulous, but the 
degree of expansion differs 
in primiparse from that in 
multipara. In the former, 
after the fourth or fifth 
month, it gets slightly pat- 
ulous, but will not receive 
the end of the finger till a 
much later period. Even 
at the eighth or middle of 
the ninth month, the mar- 
gin of the os is pretty close- 
ly contracted. The cavity 
of the cervix is wide, and 
Cervix uteri beyond the seventh month. j£ foe fjjjger fo e pushed 

through the external os, it readily passes to the situation of the 
internal os. 

In pluriparse the cervical changes are somewhat influenced by 
the experiences of former pregnancies and labors. The cervical 
canal does not assume the spindle shape, but rather resembles a 
thimble. The os tincae is more widely expanded, so that at the 
seventh month the finger easily enters the cervical canal, and ap- 
proaches the internal os. At the eighth month the latter, as a 
rule, has begun slightly to yield, though on one hand it may re- 
main closely shut till the close of gestation, and, on the other, it 




132 CHANGES EESULTING FBOM PKEGNANCY. 

may be so widely expanded as to admit two fingers. Lusk* 
mentions the case of a multipara whom he had occasion to ex- 
amine toward the end of gestation to determine the question as 
to the safety of her making a railroad journey to a neighboring 
city. He found the cervix soft, the head low, and the internal 
os dilated to the size of a dollar. Two weeks later, he was call- 
ed to see her in the early stage of labor, and found that, under 
the influence of uterine contractions, the canal of the cervix had 
again closed. 

Vaginal and Yulvar Changes. — In the vagina, changes take 
place corresponding in some regards to those in the uterus. The 
muscular fibres hypertrophy; the vessels of the venous plexuses 
increase in size, and impart a blue, or purple color, to the vaginal 
walls. The mucous membrane becomes thickened, and increased 
in length, so that though the vaginal tube is drawn upon by ascent 
of the uterus, the anterior of the vagina not unfrequently pro- 
trudes from the vulva. The papillae enlarge and impart a rough 
feel to the finger. 

There is also turgescence of the vulva, pouting of the labia, 
duskiness of the mucous surfaces, and abundant secretion of the 
follicles. 

Changes in the Mammse. — Before impregnation the breasts 
are firm and nearly hemispherical; but during pregnancy they 
increase in size, and present other changes which demand con- 
sideration. The phenomena observed in these glands are due to 
swelling of the connective tissue, development of glandular acini 
along the course of the lactiferous ducts, and increased deposi- 
tion of fat between the lobes. Enlargement of the organs is not 
noticeable until the fourth month, though from an early period 
in pregnancy there is a painful sensation of fulness in them. 
The veins enlarge and become unusually distinct as they course 
beneath the skin, and as distention finally becomes excessive, 
the cutis yields in places, presenting reddish or white lines like 
those found on the abdomen. 

The nipples become turgid, prominent, sensitive, and, on slight 
stimulation, erect. The most diagnostic changes, however, take 
place in the areola. Often as early as the second month the sur- 
face of this part is soft and oedematous, and slightly elevated. 

* " Science and Art of Midwifery," p. 88. 



CHANGES IN THE MAMMJ1. 133 

The sebaceous follicles enlarge, and after a time moisten the 
areola with their secretions. About the middle of pregnancy, 
discoloration, arising from a deposit of pigment, is noticeable. 
It is more marked in women of dark complexion, and, from the 
fact that it is more or less permanent, the sign is of value mainly in 
primiparse. 

Fig. 82. 



Showing the appearance of the areola. 

In the latter months of pregnancy, about the border of the 
areola is observed a ring presenting a peculiar appearance, called 
the secondary areola of Montgomery. The character of it is 
better depicted in the accompanying cut than in any written de- 
scription. Briefly stated, it looks as though the color had there 
been discharged by a shower of drops. The appearance is due 
to the presence of enlarged sebaceous follicles devoid of pigment. 

Other Tissue Changes. — The connective tissue interposed 
between the layers of the broad ligaments, and around the ute- 
rus, becomes slightly infiltrated with serum. The lymphatics 
also enlarge, from the increased work put upon them. Fat is 
deposited in the subcutaneous tissues of the pelvic region, giving 
to the hips increased breadth. 



134 



CHANGES RESULTING FROM PREGNANCY. 



Abdominal Changes. — As the uterine development goes on, 
the abdominal walls are put upon the stretch, and, in women 
who are well nourished, are increased in thickness by the abun- 
dant formation of adipose tissue. The umbilical appearances 
are altered from stage to stage. At first, from causes before 
explained, there is marked retraction of the part. This becomes 
progressively less, until, at the seventh or eighth month, it be- 
gins to assume the exact counterpart of its former appearance, 
by becoming prominent, from the pressure exerted from within. 
Abdominal distention also gives rise to the formation of reddish 
streaks, or striae, which, after delivery, become bleached, so as to 
resemble cicatrices. They are found more especially upon the 



Fig. 83. 



Fig 84. 





LateralView at sixth month. 



Lateral view at ninth month. 



sides of the abdomen, where they form sinuous lines, varying 
in length. They are due to an atrophic condition of the skin- 
layers, to partial obliteration of the lymph-spaces, and to con- 
densation of the connective tissue elements, which, instead of 



BLOOD CHANGES. 135 

forming rhomboid meshes, run parallel to one another.* They 
are merely the result of distention, and are not peculiar to preg- 
nancy. 

Relation of the Uterus to Surrounding Parts.— Toward 
the close of gestation the uterus lies with its anterior surface 
directly in contact with the abdominal walls, the intestines hav- 
ing been crowded upward and backward until they surround the 
uterus like an arch. Its lower anterior surface rests upon the 
posterior surface of the symphysis pubis, and the lower aterine 
segment dips, to a certain extent, into the pelvic cavity. The 
posterior uterine surface lies in relation to the spine, by which 
it is made to assume a slight lateral obliquity. 

Functional Disturbance of Neighboring Pelvic Organs. — 

The pressure exerted by the gravid uterus creates functional 
disturbances in the neighboring pelvic organs. Pressure on the 
bladder, at its cervix and fundus, produces a desire for frequent 
micturition. The rectum and intestines generally become inac- 
tive, and the resulting constipation is an annoying complication 
of the pregnant state. Pressure on the sacral nerves causes 
pains in the thighs and legs; also cramps and difficult locomo- 
tion. (Edema of the lower half of the body, and varicose con- 
dition of the veins of the legs, rectum and vulva, arise mainly 
from pressure, but partly from vascular fulness of the pelvic 
vessels, induced by pregnancy. 

Changes in the Blood. — Amongst the most important altera- 
tions in the female organism brought about by the pregnant 
state, are the changes which occur in the circulating fluid. At 
one time it was a common notion that, during pregnancy, the 
woman was nearly always in a condition analagous to plethora, 
and to this state of the vascular system were referred the many 
ills of which pregnant women complain, such as headache, pal- 
pitation, singing in the ears, and shortness of breath. With 
these ideas of pathology, the treatment applied was logical, re- 
sort being had to active anti-phlogistic medication, low diet, and 
frequently to venesections. We are told that it was not un- 

* Btjsey— " The Cicatrices of Pregnancy."— Trans. Am. Gyn. Soc'y, Vol. IV., 
page 141. 



136 CHANGES RESULTING FROM PREGNANCY. 

common for women to be bled six or eight times during the latter 
months of gestation, and we have the record of cases wherein such 
depletion was practiced as a matter of routine, every two weeks, 
and sometimes much oftener. 

Modern research appears to have conclusively demonstrated 
that there is an increase in the quantity of the circulating fluid, 
to correspond with the enormous vascular development.* The 
increase is mainly of serum, but the number of white blood cor- 
puscles, and the quantity of fibrin are both augmented. On the 
other hand there is a decrease in the number of red blood cor- 
puscles, the quantity of albumen, iron and salts of the blood. 

Inasmuch as there is an increase in the total quantity of blood, 
the proper maintenance of the circulation would demand an in- 
crease either in the frequency of the heart pulsations, or in the 
quantity of blood forced into the large vessels with each cardiac 
systole. Observation of pregnant women teaches us that the 
first alternative is not true, the action of the heart is not accel- 
erated. The compensation, then, is in dilatation of the heart 
cavities and hypertrophy of the left ventricle, the auricles and 
right ventricle remaining unaffected. As a result of these 
changes, there is increased arterial tension, which imparts a full- 
ness to the pulse, formerly misunderstood. According to Duro- 
ziezf the heart remains enlarged during lactation, but is rapidly 
diminished in size in women who do not suckle. In those who 
have borne many children the organ remains permanently some- 
what larger than in nulliparae. 

Tarnier says that in women who have died after delivery, the 
organs always show signs of fatty degeneration. We are told 
by Gassner that the whole body increases in weight during the 
latter part of pregnancy, and this increase is somewhat beyond 
what can be explained by the size of the womb and its contents. 

Formation of Osteophytes.— Thin bone-like lamellae, con- 
sisting chiefly of phosphate and carbonate of lime, are found 
deposited on the inner surface of the skull in rather more than 
half the women who have died late in pregnancy, or soon after 

* Vide •' Untersuchungen iiber die Blutmenge trachtiger Hiinde." " Arch. f. 
Gynaek." Bd. iv, p. 112. 

f Gaz. des Hopit, 1868; 



OTHER CHANGES. 137 

delivery. These lamellae, which measure one-sixth to one-half 
line in thickness, are by Rokitansky termed osteophytes. They 
begin to form about the third month, and are found chiefly upon 
the frontal and parietal bones. They are not peculiar to preg- 
nancy, but are likewise often found in consumptives. 

Miscellaneous Changes. — The nervous system generally be- 
comes more impressionable. There are alterations in the intel- 
lectual functions, changes in disposition and character, morbid, 
capricious appetite, dizziness, neuralgia and syncope. Melan- 
cholia is sometimes met, which in women predisposed thereto, 
occasionally ends in mania. The memory is often weakened, 
especially when one pregnancy follows another in rapid succes- 
sion. On the contrary, the nervous system sometimes becomes 
calm and strong, and the woman experiences a peculiar sense of 
well-being. 

Respiration becomes difficult from mechanical causes, espec- 
ially at a time just previous to the subsidence of the uterus here- 
inbefore alluded to, at which time, according to Dohrn, there is 
a diminution in the vital capacity of the lungs. The thorax is 
increased in breadth, and diminished in depth. 

Gastric disturbances are common in pregnancy. Nausea and 
vomiting, which, from their most frequent occurrence in the 
morning, have been called " morning sickness," are experienced 
by the majority of women during the early weeks. The author 
has found, however, upon careful inquiry of women presenting 
themselves for confinement in Hahnemann Hospital, that about 
forty per cent of all cases entirely escape the annoying complica- 
tion. It generally begins at about the sixth week of pregnancy, and 
continues for from six days to six or seven weeks. In other 
cases it is a complication of later gestation. The appetite is 
capricious, the longings being in some cases for even disgusting 
articles of food. Increased flow of saliva is often a marked 
symptom. The bowels are sometimes loose, but constipation is 
more common. 

It is not surprising to observe that the health of women is 
somewhat impaired during the first- three months of pregnancy. 
After that time, however, there is generally an improvement — 
the appetite returns, digestion becomes more active, and assimi- 



138 CHANGES RESULTING FROM PREGNANCY 

lation recruits the strength and increases the weight. Gassner* 
estimates the total increase at about one-thirteenth the entire 
weight of the body. 

Besides the pigmentation of the areola about the nipple, there 
is discoloration of the linea alba of the abdomen, and at times 
maculae appear on different parts of the body, particularly the 
face, but, as a rule, disappear after delivery. 

Certain changes in the urine have, by some, been considered 
pathognomonic of pregnancy. These consist in the formation 
of a deposit when the urine is allowed to stand for a considera- 
ble time, which has been called Kiestein. It is observed after 
the second month of pregnancy, and up to the seventh or eighth. 
From the fact that a precisely similar substance is sometimes 
found in the urine of women who are not pregnant, especially if 
anaemic, and even in the urine of men, it cannot be regarded as 
a change peculiar to pregnancy. 

The Permanent Changes. — The uterus after delivery does 
not resume its nulliparous shape and size, but retains vestiges 
of the condition through which it has passed. The weight of the 
organ is increased to about an ounce and a half; the fundus and 
body are rounded externally; the cavity of the body loses its tri- 
angular shape, and becomes much larger relatively to the cervix, 
while the os internum is left somewhat agape. The mucous 
folds of the cervix are in great measure obliterated, or, at least, 
are rendered indistinct, and the os externum is patent. Abdo- 
minal distention leaves indelible marks in the shape of the striae 
mentioned, which, from a reddish or brown color, become sil- 
very-white like cicatrices. The pigmentation of the linea alba 
is never wholly removed. The breasts give evidence of former 
pregnancy in the existence of the silvery lines alluded to, and the 
discoloration of the areola which has, in a measure, remained. 
In addition to these changes there are doubtless many which 
mark a difference between women who have borne children, and 
those who have not, but further evidence is, in the main, refera- 
ble to parturient effects. 

* " Monatsschr f. Geburtsk," Bd, xix. p. 1. 



THE DIAGNOSIS OF PREGNANCY. 139 



CHAPTEB IV. 

The Diagnosis of Pregnancy. 

The diagnosis of pregnancy, from the obscurity and indeter- 
minate character of early symptoms, and the weighty contingent 
cies which hang upon the expressed conviction arising from 
examination, is one of the most trying duties which the physician 
is called to perform. It is further intensified by the notion so 
prevalent among people, that the signs of pregnancy, from the 
first, are, or should be, to the trained and skillful observer, 
clearly legible. 

In most cases wherein this interesting condition is suspected 
to exist, the woman is within marital bonds, and diagnosis is 
sought more from the promptings of curiosity than any other 
consideration. Such women, as a rule, are easily pacified with 
an equivocal answer. In other cases there is an entirely differ- 
ent posture of affairs, and diagnosis is requested not out of idle 
curiosity, or to satisfy a momentary whim, but from the pressure 
of dire forebodings. The woman is not under the safe protection 
of marriage vows, and, urged on by her fast-augmenting fears, 
or stimulated by an impugning conscience, she seeks positive 
knowledge. Again the physician is consulted, not by the woman 
herself, but by her friends. Parents, perhaps, with, or without, 
heart-sickening suspicions of their daughter's unchastity, desire 
an explanation of the objective and subjective symptoms which 
have come to their knowledge. In many such cases so much de- 
pends upon the diagnosis rendered, that an error will not be par- 
doned. The symptoms may be ambiguous, and a most careful 
investigation may not elicit conclusive evidence, but by the con- 
viction expressed the physician has generally to abide. No plea 
of having done as well as circumstances allowed, will atone for a 
mistaken opinion. A confession of error will not bind up a broken 
heart, nor restore the lustre to a tarnished reputation, Further- 
more, the physician is sometimes called upon for an opinion in 



140 DIAGNOSIS OF PEEGNANCY. 

cases under litigation wherein alleged gravidity is an important 
factor. Final adjudication in fixing responsibility, or in direct- 
ing the inheritance of property, may be determined largely by 
the effect of his expert testimony. 

Classification of the Signs. — The signs of pregnancy should 
always be classified as relative or presumptive, and positive or 
demonstrable signs. Upon one, or upon a number of the former, 
nothing more substantial, affirmatively, than probabilities, of 
various degrees of intensity, can be predicated. An unequivo- 
cal affirmative diagnosis ought never to be given. The presump- 
tive evidence may be so strong in certain instances as to leave 
few and feeble possibilities of error, and yet experience teaches 
the fallacy of drawing absolute conclusions from such data. 
There are three signs which are generally regarded as positive, 
viz. : foetal movements, ballottement, and the sounds of the foetal 
heart. By some teachers, however, the last alone is regarded as 
unconditionally positive, and thus we here teach. 

Subjective and Objective Signs.— In the diagnosis of preg- 
nancy subjective symptoms should receive due consideration, but 
objective symptoms must constitute our main reliance. Women 
are too prone to draw their conclusions from intuitions and men- 
tal impressions, and as a result we sometimes have graviditas 
nervosa, disconnected, perhaps, with even the most common and 
essential physical indications of pregnancy. 

History of the Case.— Items of importance may be gathered 
from a recital of the history of the case, which should include 
an account of the mode of development, and the order in which 
the various observable and sensible signs were manifested. 

The Menstrual Flow ought to be carefully inquired after. 
There may have been a regular return of it throughout the sup- 
posed pregnancy; or there may be complete suppression. Should 
the former condition prevail it will justly arouse suspicion. In 
that case, ascertain wherein the catamenia deviate from a nor- 
mal standard. If menstruation has ceased, learn the circum- 
stances under which it disappeared, and the peculiarities, if any, 
which characterized the last two or three "periods." 

Pregnancy in Women Who Do Not Menstruate.— Cases are 
on record wherein young women have conceived before the men- 
strual function had been established. During lactation and sus- 
pension of menstruation, impregnation often occurs. 



INSPECTION. 141 

66 Morning Sickness" — a sign of some value — is largely sub- 
jective, and concerning it strict inquiry should be made. When 
was it first felt ? At what times, and under what circumstances 
was it most troublesome ? How long did it last ? 

When quickening is alleged to have taken place, try to fix the 
date, and the precise sensations experienced. 

Unreliability of Subjective Symptoms.— With regard to 
information thus elicited from women, it should be observed 
that, while it affords valuable data to be used in constructing a 
diagnosis, it is liable to be wholly fallacious. The menstrual 
function may, or may not be suppressed, and she may, or may 
not have experienced morning sickness and foetal quickening. 
Facts are extremely liable to be distorted (not always purposely) 
by surrounding circumstances, and the woman's mental state. 

Menstruation During Pregnancy. — It is hot very uncommon 
for a woman to menstruate once, twice or thrice after impregna- 
tion, and cases are recorded wherein the catamenia returned with 
regularity throughout utero-gestation. Various theories have 
been advanced in explanation of the anomaly, but most observ- 
ers now concur in ascribing the flow to its usual source. This is 
rendered probable by the well established fact that the decidua 
reflxa does not come into intimate relation with the decidua vera, 
over the entire surface of the uterine cavity, until after the third 
month. 

Objective Symptoms.— We must depend, then, almost wholly 
on objective symptoms as a basis for diagnosis. The same com- 
mon means of investigation are available here as in other cases 
where physical examination is required. They are— Inspection, 
Palpation (including "the touch"), Percussion, and Ausculation, 
the relative value of which, and the methods of most effective 
use, will be briefly considered. 

Inspection.— Inspection will aid very materially in perplex- 
ing cases, in carrying the inquirer to a correct decision. The 
form of a woman who has reached the fifth month of gestation 
is quite diagnostic even when purposely obscured to a certain 
degree by the apparel. The experienced observer is often able, 
by inspection of the form, to differentiate between pregnancy 
and simulating conditions. The precise outline of the gravid 
abdomen varies but within limits which make all cases quite 



142 DIAGNOSIS OF PREGNANCY. 

similar. As we take a lateral view of a pregnant woman, the ab- 
dominal enlargement is seen not to be equable, but its point of 
greatest projection is near its superior boundary. This pecul-' 
iarity becomes more and more characteristic as pregnancy ad- 
vances. The cause of this is obvious when we recollect the form 
of the uterus, and the direction of its long axis, it being at an 
angle with the horizon of about 60 ° . 

This lateral view is of considerable value in the diagnosis of 
pregnancy. Mere circumferential measurements are of com- 
paratively little importance. 

A front view also of the abdominal tumor, taken when the 
woman is either standing or lying, reveals diagnostic characters. 
They are more marked in the erect position. First should be 
observed the absence of prominences and irregularities. It is 
not uncommon to find a difference between the two sides, in point 
of fulness, but it is not confined to a circumscribed area. This 
is generally produced by the presence of the foetal trunk, as the 
writer has repeatedly demonstrated. Then, too, the tumor aris- 
ing from pregnancy is narrower, and more prominent along the 
middle line, than is the pathological tumor. 

Special abdominal appearances, aside from enlargement, should 
be remembered. During the first few weeks of utero-gestation, 
the abdomen, instead of being enlarged, is really retracted or 
flattened. This is especially true of the umbilical region. This 
phenomenon has already been explained. The uterus, from its 
uncommon weight, proceeding in part from actual increase in 
size, but largely from vascular engorgement, sinks in the pelvic 
cavity to an unnatural level, and in doing so drags upon the 
bladder, which, in turn, through the urachus, causes the retrac- 
tion mentioned. 

The linea alba of the abdomen, from a deposit of pigment, 
loses its usual appearance. 

Foetal movements are often discernible. They are sometimes 
closely simulated by spasmodic muscular action, when, as a 
means of differentiation, palpation affords positive aid. 

Inspection of the breasts is a valuable means of diagnosis, by 
means of which the changes described in the preceding chapter 
will be observed. The appearance known as the " secondary 
areola of Montgomery," should receive special attention. 

The changes in the vaginal mucous membrane must be seen to 



PALPATION. 143 

be known, but when once familiar to the eye will afford consid- 
erable aid. 

The foregoing embrace an allusion to the principal applica- 
tions of this means of investigation. When intelligently em- 
ployed it furnishes valuable aid in perplexing cases. 

Palpation. — If deprived of every sense but the tactile, the 
physician would still retain the means for making a positive 
diagnosis in nearly all cases of suspected pregnancy. This mode 
of examination is in common use, and is highly regarded, yet 
there are many, even among those long in practice, who, from 
lack of adequate comprehension of its possibilities, do not value 
it as highly as they ought. Abdominal palpation alone is suffi- 
cient, in many ambiguous cases, to effectually dispel doubt. In 
early pregnancies it is not capable of such achievements, but 
when combined with the vaginal touch, it becomes a most valu- 
able help. Later, however, the uterus, with its developing foetus, 
rises within easy reach of the hand, and admits of minute ex- 
amination. The fundus uteri is always easily distinguishable, 
and its height can be clearly determined. Its peculiar form, 
with broad, even surface, is highly characteristic. Its lateral 
superficies can also generally be felt. If the examination is 
prolonged, the recurrent uterine contractions which are going on 
throughout the greater part of pregnancy, will be felt under the 
hand; and during their prevalence, a pretty good outline of the 
gravid uterus may be distinguished. At the moment of con- 
traction, the surface of the uterus which comes under examination, 
when not defaced by fibrous growth, will convey to the hand 
a smooth, regular feel. In the intervals between contractions, 
when there is no muscular resistance, it is possible after the 
middle of pregnancy, to feel the foetal form through the uterine 
walls. At this period, and later, there is in many cases so great 
a relative redundancy of liquor amnii as to admit of remarkable 
foetal mobility. The head, if not presenting closely at the brim, 
as it frequently at this season is not, may easily be moved from 
onQ side of the abdomen to the other. In a modified degree this 
is also true of the extremities and trunk. The foetal movements, 
whether spontaneous or elicited, are easily felt by the palpating 
hand. If the abdominal walls are thin, as in women of sparo 
habit, palpation is capable of affording highly satisfactory evi- 
dence upon which to base diagnosis. 



144 DIAGNOSIS OF PREGNANCY. 

In many cases, by deep pressure, the abdominal walls below 
the umbilicus can be depressed until the fingers touch the spine, 
in which case the physician may rest assured that there is no 
pregnancy, or that it has not advanced beyond the third or fourth 
month. If in making such an attempt, resistance is at once en- 
countered, thorough examination by deep pressure and conjoint 
touch should be made, to learn the nature of it. 

"The touch" is a highly efficacious mode of examination, and 
one which, in cases at all doubtful, ought never to be neglected. 
By means of it several important signs may be elicited. In the 
early weeks, the uterus, as before observed, lies lower in the 
pelvic cavity than during a non-pregnant state. This condition 
by itself would be of no significance, and, at best, is but a feeble 
relative sign. After the third month, the uterus having risen so 
that its bulk lies above the pelvic brim, the cervix is elevated 
and turned backward toward the rectum, thereby putting the 
roof of the anterior vaginal cul-de-sac on the stretch. This is a 
valuable relative sign when found as a concomitant of other 
affirmative conditions. 

Cervical Softening. — The marked changes in the cervix uteri 
which begin soon after impregnation and gradually progress to 
full consummation, have been described elsewhere. At the close 
of the eighth or ninth week the lips of the os uteri communicate 
to the examining finger a slight sensation of softness, at that time 
due, perhaps, in the main, to turgescence and tumefaction of the 
part, but doubtless attributable, in a measure, to special physiolog- 
ical softening of the uterine neck, dependent on other causes. The 
process begins at the lowermost part and progressively as- 
cends. An examination made at the sixth month discloses soft- 
ening to the extent of half its length. Not until near the close 
of gestation is the process completed. The gradually increasing 
expansion and dilatability of the os uteri which accompanies the 
cervical softening, ought to be kept in mind during examination. 

The period at which the internal os uteri gives way, so that 
the cervical canal becomes part of the uterine cavity admits of 
some diversity of opinion. It is the author's conviction (else- 
where expressed), based upon special observation of many cases, 
that it is not brought about until, or very near, the beginning of 
labor, and frequently not until pains have been present for some 
time. If this is true, the progressive shortening of the cervix 
generally described is more apparent than real. 



PEBCUSSION. 145 

Allusion has been made to the diagnostic value of conjoint 
examination, i c, abdominal palpation employed in connection 
with the vaginal touch. By such manipulation it is possible to 
form an approximate estimate of the size of the uterus, and 
hence the probability or improbability of pregnancy. It should 
be indulged with due caution, as harshness is liable to produce 
most unwelcome results. 

There is a form of vaginal, or bimanual examination, the em- 
ployment of which, at certain stages, will disclose a sign of 
pregnancy by some regarded as positive, namely, ballottement. 
It can be practiced by both hands upon the abdomen. To do so 
the woman must be placed on her side, one of the operator's 
hands resting above, and the other below the abdomen as she lies. 
By a sudden movement of the hand beneath the foetus, the latter 
may be displaced or tossed, and the impulse of its return com- 
municated to the keen sense of the operator. 

Vaginal ballottement is performed by placing the woman on 
her back in a semi-recumbent posture, and then, with two fin- 
gers in the vagina, the uterine wall just interiorly to the cervix 
is given a sudden push in the direction of the long uterine axis. 
This propels the foetus away from the lower uterine segment, 
but it soon sinks again in the liquor amnii, and the gentle tap 
of its contact with the uterine tissues may be felt. When clearly 
elicited, it is regarded as a positive sign of pregnancy, but owing 
to the skill and experience required to successfully practice the 
manoeuvre, it has here been classed as a relative sign. It can- 
not be employed with satisfaction earlier than about the close of 
the fourth month, nor later than the seventh. 

Uterine fluctuation may sometimes be felt, according to Dr. 
Kosch,* by conjoint manipulation — the hand on the abdomen, 
and two fingers in the vagina ; but the delicacy of the sign ren- 
ders it unreliable for geneial use. It is recommended as a 
means of early diagnosis. 

Percussion.— This means of diagnosis fills but a small niche. 
The abdomen in real gravidity gives, on percussion, sounds 
mostly flat, always dull. Should resonance be obtained over the 
site ot the enlargement, it may justly be regarded as almost con- 
clusive evidence of non-pregnancy. It can be employed to con- 

* British Mechcai Journal, vol. ii., 1873. 



14:6 DIAGNOSIS OF PREGNANCY. 

firm other indications, bnt as a means of positive diagnosis it 
possesses no merit. 

Auscultation. — When Mayor, of Geneva, tentatively applied 
his ear to the abdomen of a pregnant woman in the hope that 
he might hear foetal movements, and discovered the inaudibility 
of these, bnt heard the unmistakably clear sounds of the foetal 
heart, he brought within command a means of diagnosis at once 
easy of application and unequivocal in indication. The fcetal 
heart-beat is the positive sign of pregnancy. 

The sounds have been compared to those of a watch under a 
pillow, but an infinitely better idea of them may be obtained by 
listening to the heart of a new-born child. They were first heard 
by Mayor with the unaided ear, but we ought not to infer from 
this that immediate ausculation is preferable. The author has 
repeatedly demonstrated the superiority of the mediate mode. 
The double stethoscope gives best satisfaction. The instrument 
may be applied by firni or by light pressure, the latter being 
preferable. To properly do this it should be placed on the ab- 
domen in such a way that it will rest evenly, and lightly, and 
then the fingers entirely removed. Sounds can thus be heard 
which would otherwise be absolutely inaudible. This method of 
using the stethoscope requires considerable practice to obtain 
the best results. 

The area of audibility depends mainly on the position and 
presentation of the foetus. The sounds are conveyed to the ear 
most intensely by solid tissues or substances; hence they are 
most distinct when the trunk of the foetus, at a point near the 
heart, comes in contact with the uterine walls, and the uterine 
walls are in turn brought firmly against the abdominal parietes. 
A dorso-anterior position of the foetus is most favorable for 
transmitting the impulse. The area of audibility varies consid- 
erably in extent. In one case the sounds can be heard over 
nearly the whole abdomen; while in another they are circum- 
scribed to a small space. When audible over an extensive area 
there is always a point where the summum of intensity is reached. 
Since the left dorso-anterior position of vertex presentation is 
the most frequent, the sounds of the fcetal heart are oftener 
heard on the left side below the umbilicus. When the child is 
in the fourth position, the sounds are also on the left side. In 
second and third positions, on the right side. In cephalic pres- 



AUSCULTATION. 147 

entation the area of audibility is lower than in pelvic presenta- 
tion. 

The rapidity of. pulsation varies greatly, the average being 
about 134 beats per minute. 

Observers are not in accord regarding the period in pregnancy 
at which the foetal heart is first audible. Practice will enable 
one listener to detect it at an earlier age than another of less ex- 
perience. De Paul says he has heard the sounds at the eleventh 
week. Naegle could not distinguish them before the eighteenth 
week, and his experience in this regard is a counterpart of the 
average skilled practitioner. 

What was formerly termed the "placental souffle," and re- 
garded as a certain sign of pregnancy, is now more appropriately 
known as the uterine, or abdominal souffle. This bruit instead 
of proceeding from the utero-placental circulation, and marking 
the placental site, is probably occasioned by the uterine and ab- 
dominal circu]ation, the vessels of which in places are subject to 
pressure, and emit a blowing or purring sound. Large abdomi- 
nal tumors, disconnected with pregnancy, also give rise to the 
same, or a similar bruit. It may be modified, or entirely ar- 
rested, by the pressure of the stethoscope. 

As a sign of pregnancy, it doubtless possesses some value, but 
it must not be admitted as a certain sign, and under no circum- 
stances is it to be regarded as proof of the life of the foetus. It 
is now well understood that by auscultation of the abdomen of 
a pregnant woman, we may hear the pulsations of the foetal heart, 
and the bruit de souffle ; in some cases foetal movements and the 
funic souffle. The first named is a pretty constant sign of preg- 
nancy ; the second is of value only when it is certan that the 
woman has no other disease which can possibly give rise to it ; 
while the third and fourth are so rarely audible in one instance, 
and so ambiguous in the other, as to be of little real value. 

The following summary of the signs of pregnancy may prove 
of service : 



148 



THE DIAGNOSIS OF PREGNANCY. 



£6 



E£ 



E S3 .5 



^ E 



?*, 



4> R ii 



e a 



o"rt •*» JiH 

•a E^gi: 






1«| 



jx rt 



£ 5 



3 4JT3 



- 6 

4) >. 

Oh o 



3 rt-3 
3 bJOC 
oon 
"> a a, 
c >>S 

a- 5 >. J 






fa |'- 



i-1 l« 






"o E SP 

fa££ 



j, -a 
- ."« 

o 3 
! rt rt 



fac/3"rtl3 

3 a 



_, >» —I « 

"* o <2 C « ■ 
•£> s'SdE ' 

._ u n to; 

c3 £ > 8 

o o !J (■ i 
■fjjS o.2 S3 
y ^ c S3 %• 

, s.p 

3 



3^ 



S£ 



<^ „ Sj J 






3 ^ i. ° c ?3 



bcU. 



i C " 4) I< 
3 rtC/3T3 3 



£§ 



«3^ 

&<j rt 

. rt 
£.3.3 
'35 * ST 

CO p> i 



S E 



■a ^ S 

fa « « 



3 o 
</> rt 

3 a 

B.g 

O 
C « 



5^ 



IS 

3 rt 
G 

o'E 
o 

ll § 
2-g .1 

is « bDj~ 

^ IB.S « 



w mjs o « 



S « S'CiS E 
•7! u u rt ci 



3 E* S E 

'5 E 



3.T3£ 

5^-g 8 



s a 



E-Sid 



3 1 : 



* e" 



R c 



.jagg's - s 

OO '0-0^™J?c 

8 E-s^^.y£ E~ 
aCJ E «0 uS %U 
3 2-5 ■£ =3 



to £P£ =•" 
S2 C U 3 
in 'S » <" a* 

-. 8 5 o- 8 

p E£ >| E 

be « c. 



E a a 



C rt C 






DIFFERENTIAL DIAGNOSIS. 149 

Differential Diagnosis. — The subject of the diagnosis of 
pregnancy would be far from complete without a few observa- 
tions on differential diagnosis. It would be impossible to mention 
in a short chapter all those various conditions which are liable 
to be mistaken for pregnancy. 

TThen there is an enlarged abdomen which raises a suspicion 
of pregnancy, combined internal and external examination is 
highly important. Upon employing it a tumor of some sort may 
be discovered, but, if extra-uterine, by careful manipulation of 
the cervix the uterus can generally be made out as a distinct and 
free organ, with walls which are not greatly distended. To pass 
the uterine sound is rarely necessary, except to render assurance 
doubly sure. If serious doubts are felt, it would be an unjusti- 
fiable act. The feel of the lower uterine segment, in connection 
with other signs, is diagnostic. From the second to the fourth 
month the gravid uterus is peculiarly soft, while, if tumors are 
present, it is harder. In hsematometra it is firm, but elastic, and 
may even give fluctuation. In chronic inflammation, the uterus 
is sometimes rather soft, but usually it is much harder than in 
pregnancy. Then, too, if inflammation exists, other symptoms, 
such as tenderness and pain, will strengthen diagnosis. In both 
hsematometra and interstitial fibroids, there is greater firmness of 
the uterine tissues, and the cervix disappears early. Diagnosis 
in some cases may still be uncertain at the first examination, but 
the lapse of a few weeks will clear up the doubtful points. 
Should the fibroids form knobby projections, as they most fre- 
quently do, abdominal palpation would contribute the requisite 
certainty to the differentiation. 

An exact diagnosis of pregnancy is often impossible even at 
the third month, but again it may be made with a reasonable de- 
gree of certainty. If the organ is found slightly anteflexed, and 
corresponding in size to the probable period of gestation, not 
painful to manipulation, of a peculiar softness, and, moreover, 
the woman healthy, though her menses have not appeared dur- 
ing the time, then, every probability leads to the one conclusion. 
The inexperienced, however, will act a wise part to make their 
diagnosis with a distinct reservation. 

At a subsequent period differentiation of the physical condi- 
tion becomes less difficult, quickening, ballottement and the foetal 
heart-sounds clearing away all doubt. But, at the fourth or fifth 



150 DIAGNOSIS OF PREGNANCY. 

month, though the absolute signs of pregnancy are absent, as in 
the instance of dead ovum, or uterine mole, development of the 
organ has gone to so great an extent that the real condition may 
be determined with the utmost certainty. 

In those cases where pregnancy exists in connection with mor- 
bid conditions, the former is sometimes overlooked, not so much 
because the symptoms of such a state are absent, as that they 
are not so prominent as those of the diseased conditions. The 
latter are generally discerned without difficulty, and further in- 
vestigation is neglected. In these complicated cases, should 
there be a suspicion of pregnancy, repeated careful examinations 
will either confirm or remove it; and no measures should be 
adopted for the treatment of disease in women, which would be 
prejudicial to the pregnant state, without the possibility of such 
a state receiving due consideration. 

Diagnosis ol Foetal Death.— This is a highly important 
consideration. The circumstances which may give rise to a sus- 
picion that the foetus is dead are : 1. Absence of f cetal movements. 
2. Absence of the foetal heart-sounds. 3. Diminished size and 
increased softness of the uterus. 4. Flaccidity of the mammas. 
5. Sensation of weight and coldness in the abdomen. 6. Debil- 
ity and general ill feeling. 

Concerning the first, we need not hesitate to declare it wholly 
unreliable, and, when once active uterine effort has begun, it is 
devoid of significance. With respect to the second, it should be 
understood that in certain cases the sounds of the foetal heart 
are inaudible for a considerable period, while yet the child is 
vigorous. The physical signs three and four, may depend upon 
causes which do not involve foetal death, while numbers Rye and 
six, being subjective symptoms, are of very slight relative value. 
" Certainty of death having taken place," says Schroeder,* " is 
obtained only when the os is open and allows the loose cranial 
bones to be felt distinctly; also when the sounds of the foetal 
heart, which, in the absence of other pathological conditions can 
always be distinguished by a repeated careful examination, can- 
not be heard." 

Signs of Foetal Death Evinced During Labor.— After labor 
has begun, the signs of foetal death have reference only to the 

* •' Manual of Midwifery." Applton & Co., 1873, p. 53 



DURATION OF PREGNANCY. 151 

child itself, and they are generally so clear as to dispel all doubt. 
1. The results of auscultation are almost conclusive, since, dur- 
ing parturition, the conditions favorable for the transmission of 
the foetal heart-sounds are at their best, and can hardly fail to 
be successfully made use of by even a novice. 2. On the head 
of a dead foetus no caput succedaneum is formed. The presence 
of such tumefaction is conclusive evidence of life, as it is the 
effect of long-continued pressure, and circumscribed arrest of 
the circulation. 3. The scalp of a dead foetus is flabby and soft; 
the bones are movable, and overlap more than usual ; their edges 
feel sharp, and on pressure communicate to the fingers a grating 
sensation. The heads of poorly-nourished, but living children, 
sometimes present these peculiarities. 4. The presence of meco- 
nium, and the escape of thin, slimy, offensive liquor amnii af- 
ford additional proof of death. 

If the breech presents, the sphincter ani is relaxed, and does 
not contract on the finger. The epidermis is blistered, and is 
easily rubbed off with the finger, if the child has been dead 
more than a day or two. This is also true of other surfaces. 

If the face presents, the lips and tongue are flabby and mo- 
tionless. In arm presentations, there is no swelling, no lividity, 
no motion, and no warmth. In prolapse of the funis, the cord 
is flaccid, cold and pulseless. 



CHAPTEE V. 

The Duration of Pregnancy. 

This is a subject which has elicited much study and discus- 
sion. In settling it on a firm, scientific basis, the main obstacle 
has been the impossibility to ascertain the precise date of fer- 
tile coitus. In hospital practice, the majority of women entered 
for confinement are living outside the conjugal relationship; 
have been leading lives of repeated exposure to impregnation, 
and are unable to offer positive testimony as to the date of con- 
ception, even if so disposed to do. Others, both in and out of 



152 DIAGNOSIS OF PREGNANCY. 

hospital walls, who are unmarried, profess to have been guilty 
of but a single misstep, and are prepared to give precise dates ; 
but may we not justly withhold from such our full credence, 
since it is probable that shame prompts them to withhold a state- 
ment of indiscretions which nature has finally amplified before 
the eyes of all? The married state presents obstacles to abso- 
lute calculation fully as great as those just enumerated. On ac- 
count of these difficulties in the way of trustworthy observation, 
it has become customary to base calculations on the date of the 
last menstruation. The fallacies associated with such figures 
are conspicuous. First, the date of the last menstrual return 
cannot be held to represent the real time of impregnation, or 
even of insemination, in more than a very small percentage of 
cases, since sexual congress during menstruation is avoided by 
both parties to the act. Moreover, the time of insemination does 
not correspond to the date of impregnation, inasmuch as the 
time consumed by the spermatozoa in journeying from the 
vagina to the point of contact with the ovum represents a period 
varying from a few hours to a few days. Again, it is admitted 
by physiologists that fertile coitus may both precede and succeed 
the menstrual return, by a few days. Should it precede, the 
flow which was so near may be prevented, and a miscalculation 
made by basing the figures on the date of the last menstruation. 
Or, the - flow may come on at the usual time, in a feeble and brief 
way, even though impregnation has existed for several days. 
Allusion should here be made also to those anomalous cases 
wherein conception is succeeded for two, three, or four months 
by regular menstrual returns. Hence it appears that, at best, 
such a basis of calculation is not settled nor reassuring. 

We gather some information on the average duration of preg- 
nancy from a study of comparative physiology. Valuable ob- 
servations have been made in the case of certain domestic ani- 
mals, in whom one coitus coincides with the period of rut. In 
1819, M. Tessier submitted to the Academie des Sciences, at 
Paris, the results of a series of investigations of this nature, which 
are worthy attention. The following is the tabular statement: 
Of 140 Cows : 

14 Calved between the 241st and the 266th day. 
53 " " " 269th " 280th " 
68 " " " 280th " 290th " 
5 " u " 290th " 308th " 



DURATION OF PREGNANCY. 153 

Gestation in cows is but little more protracted than in women, 
and according to this table, founded on exad observations, there 
was an extreme difference in duration of pregnancy amounting 
to 67 days. Lord Spencer made a series of observations of a 
similar nature in the case of mares. 

Of 102 Makes : 

3 Foaled on the 311th day. 

1 " " 314th " 

1 " " 325th " 

1 " " 326th " 

2 330th " 

47 " between the 340th and 350th day. 

25 " " " 356th " 360th " 

21 " " " 360th " 377th " 

1 '"on " 394th day. 

In neither of these tables has allowance been made for the 
contingency of premature labor, which probably widens the ex- 
tremes; but when a reasonable number has been deducted, on the 
strength of this presumption, there still remains evidence of 
widely variable results. It may be said in favor of the tables as 
exhibited, that, in the animals mentioned, it is highly probable 
that the influences generally regarded as productive of prema- 
ture labor were not as numerous nor as powerful as those to 
which women are subjected. 

Dr. Beid collected thirty-nine, and Dr. Montgomery fifty-six 
cases, in which pregnancy was calculated from a single coitus, 
with the following results: 

Eeid. Montgomery. Total. Duration. 

1 1 36 weeks, or 252 days. 

1 2 3 37 weeks, or 259 days. 

6 2 8 38 weeks, or 266 days. 

7 10 17 39 weeks, or 273 days. 

18 22 40 40 weeks, or 280 days. 

,2 9 11 41 weeks, or 287 days. 

3 8 11 42 weeks, or 294 days. 

2 2 4 43 weeks, or 301 days, 

39 56 95 

While there are grave doubts of the accuracy of many of these 
cases, and hence of the table as a whole, some of them are worthy 
most implicit credence. Dr. Montgomery relates the case of a lady 
who went to the sea-side in June, 1831, leaving her husband in 
town. He visited her for the first time November 10th, and re- 



154 DURATION OF PREGNANCY. 

turned to town on the succeeding day. She quickened on the 
29th of January, 1832, and was delivered August 17th, exactly 
two hundred and eighty days from the time of the last sexual 
intercourse, which was preceded by an interval of nearly five 
months. Considering the remarkable care and precision exer- 
cised by these observers, it seems probable that the results, as 
shown, approximate very closely the real facts. According to 
them, there is a wide variation in the duration of pregnancy. In 
addition to the above, there are several cases recorded where de- 
livery of what appeared to be fully-developed children occurred 
as early as 260, and as late as 284 days after a single coitus, so 
that we are led to conclude that pregnancy does not run a course 
with uniform limits. 

Schlichting * has examined 456 cases in which the day of cop- 
ulation was known, and in which the children were full term. 
He found an average duration of 270 days, but the extremes 
were very wide. 

But as it is rarely possible to determine the date of fertile 
coitus, the calculation and experience of the duration of preg- 
nancy must rest chiefly on observations, the starting point of 
which is the last day of the last menstrua. Dr. Merriman has 
accordingly conducted and recorded a series of investigations, 
which are here tabulated. Of the 150 mature births observed 
by him : 

5 were delivered in the 37th week 255th to 259th day. 

16 " " " 38th " 260th to 266th " 

21 " " " 39th " 267th to 273d " 

46 " " '• 40th " 274th to 280th " 

28 " " " 41st " 281st to 287th " 

18 " " " 42d " 288th to 294th " 

11 " " 43d " 295th to 301st " 

5 " " " 44th " ... the latest heing the 306th day. 

A difference of fifty-one days between extremes is here shown. 
Dr. James Eeid has given a table of 500 cases, in which the cal- 
culation is also from the last day of menstruation. Of these: 

23 were delivered in the 37th week 255th to 259th day. 

48 " " " 38th " 260th to 266th " 

81 " " " 39th " 267th to 273d " 

131 " " " 40th " 274th to 280th " 

112 " M 41st " 281st to 287th " 

- Arch. f. Gyn. xvi., 2, p. 231. 



DURATION OF PREGNANCY. 



155 



63 were delivered in the 42d week 288th to 294th day. 

28 " " " 43d " 295th to 301st " 

8 " " " 44th '• 302d to 308th " 

6 " " " 45th " 309th to 315th « 

The difference between extremes is here sixty days. With 
these, and other equally reliable facts before us, we are led to 
the conclusion that the average duration of pregnancy is in the 
vicinity of 278 days, though the variations are extensive. 

The Minimum. — It is interesting and important to know 
what is the shortest time within which a child may be born alive, 
and have a fair chance of life. In cases of contemplated induc- 
tion of premature labor for conservative purposes, the minimum 
time allowed the foetus is 230 to 250 days, but cases are on record 
in which life has been sustained when birth took place at a much 
earlier period. The following table by Dr. Montgomery will 
prove of interest because of the information on this subject 
which it affords: 



Last Date of 
Menses Concep'n. 

9 



No- 

1 Oct, 9 Oct. 

2 Aug. 24 

married 

3 July 22 

married 

4 

5 Apr. 10 Apr. 10 

6 Apr. 1 

7 Jan. 31 

8 Junel2 

9 Oct. 24 

10 Aug. 22 

The Maximum. 



T5TRTH -L»UKATIUN T)AV< , 
15IRTH. ofGest > n# iJAYS. 


Survival of Child. 


Apr. 3 5 M. 10 D. 161 


Twelve hours. 


Mar. 3 5 " 21 " 174 


A week. 



Jan. 18 5 " 27 " 180 131 days. 



6 " 183 Seven weeks. 

Oct. 16 6" 9 " 189 Eleven years. 

Oct. 10 6'' 13" 193 Doing well 6 m. afterward. 

Aug. 14 6 - 16 " 196 Thirty years. 

Dec. 27 6 " 18 " 198 Two years. 

May 10 6 " 19 " 199 Eleven days. 

Mar. 18 6 " 21 '• 201 Thirteen years. 

-That pregnancy is sometimes protracted be- 
yond the usual period seems now an established fact. We are nev- 
ertheless told that little more than fifty years ago opinions very 
different from those which now prevail were held by the best obsti- 
tricians. In the Gardner peerage case which came before the 
House of Lords, England, in 1825, Drs. Gooch and Davis, and 
Sir C. Clark, testified that, in their judgment the period of 280 
days was never exceeded. Subsequently, with a view to ascertain 
the experience of those who were most likely to have paid par- 
ticular attention to the subject, upwards of forty of the most 
eminent obstetric practitioners in London, Dublin and Edinburgh, 
were applied to by Dr. Keid. The large majority of these ex- 



156 DURATION OF PREGNANCY. 

pressed a firm eonviction as to the occasional extension of the 
usual period of pregnancy by a few days beyond 280. Several 
had met with one or two cases of protracted gestation, out of 
many hundred, on the exact data of which they could rely; 
others, who had not kept notes of their cases, could not offer 
positive testimony, but had no doubt that in some cases, the 
period had been extended. Some, who had had extensive private 
and hospital practice, stated that they had never met with an 
undoubted case of protracted gestation; while two affirmed their 
strong conviction that no case ever exceeds the 280th day from 
conception, and one, that it is never carried beyond the ninth 
calendar month. 

Without permitting this subject to take up too much space, it 
may be remarked that there are on record undoubted cases of 
protracted gestation, though they are probably rarely met. The 
most eminent teachers and practitioners of the day admit the 
probable truth of the proposition. Many of the cases adduced 
are valueless, because founded on insufficient data, but cases 
have been reported which merit our acceptance. 

Prediction of Date of Confinement. — The average duration 
of gestation after cessation of the menstrual flow has been found 
to be 278 days. Various methods of calculation have been sug- 
gested, and sundry periodoscopes and tables have been given, 
with a view to facilitate the prediction, and make it more accu- 
rate than it could be without them, some of which are based on 
an average of 278 and some of 280 days. 

Dr. Matthews Duncan, who has devoted much study to the 
prediction of the time of labor, has given a method of calcula- 
tion, based on an average of 278 days, which is very convenient 
and practical. His rule is: " Find the day on which the female 
ceased to menstruate, or the first day of being what she calls 
'well.' Take that day nine months forward as 275, unless Feb- 
ruary is included, in which case it is taken as 273 days. To this 
add three days in the former case, or five if February is in the 
count, to make up the 278. This 278th day should then be fixed 
on as the middle of the week, or, to make the prediction more 
accurate, of the fortnight in which the confinement is likely to 
occur, by which means allowance is made for the average varia- 
tion of either excess or deficiency." 

Naegele's method is to figure from the first day of the last 



DURATION OF PREGNANCY. 



157 



menstrual period, and then count forwards nine months, or back- 
wards three months, and to this date add seven days to complete 
the period of 280 days. 

The following table by Dr. Protheroe Smith, is easily com- 
prehended, and is probably fully as serviceable as any. 

Table for Calculating the Period of Utero-Gestation.* 



Nixe Calendar Months. 



Ten Lunar Months. 



From. 


To 


Days. 


To 


Days. 


January 1 


September 30 


273 


October 7 


280 


February 1 


October 31 


273 


November 7 


280 


March 1 


November 30 


275 


December 5 


280 


April 1 


December 31 


275 


January 5 


280 


Mayl 


January 31 


276 


February 4 


280 


June 1 


February 28 


273 


March 7 


280 


July 1 


March 31 


274 


April 6 


280 


August 1 


April 30 


273 


May 7 


280 


September 1 


May 31 


273 


June 7 


280 


October 1 


June 30. 


273 


July 7 


280 


November 1 


July 31 


273 


August 7 


280 


December 1 


August 31 


274 


September 6 


280 



The Date of Quickening. — When it is impossible to obtain 
the elate of the last menstrual period, if the time of quickening 
can be ascertained, it is customary to add twenty-two weeks for 
the purpose of determining the proximate day of delivery. 
But quickening is a sign of pregnancy which does not always 
develop in the eighteenth week, and the extreme variation in its 
manifestation in different women and different pregnancies, ren- 
ders this method of calculation a very uncertain one. 

Prediction of Time of Labor from Size of Uterus.— From 
abdominal palpation we may gather important data upon which 
to venture a prediction of the time of expected confinement. Ac- 
cording to common bedside teaching, the uterus in the second 
month is of the size of an orange ; in the third month, of the 
size of a child's head; in the fourth month, of the size of a 

* The above obstetric " Eeady Reckoner," consists of two columns, one of 
calendar, the other of lunar months, and may be read as follows : A patient 
has ceased to menstruate on July 1; her confinement may be expected at soon- 
est about March 31, (the end of nine calendar months,) or at latest on April 6, 
(the end of ten lunar months). Another has ceased to menstruate on January 
20; her confinement may be expected on September 30, plus 20 days (the end 
of nine calendar months) at soonest; or on October 7, plus 20 days (tJte end often 
lunar months) at latest. 



158 



DURATION OF PREGNANCY. 



man's head,* and can be felt above the symphysis pubis. In 
the fifth month, the fundus of the uterus rises to a point mid- 
way between the symphysis and the navel. By the sixth month, 
it reaches the level of the navel. In the seventh month, it 
should be the breadth of two or three fingers above the navel. 

In the eighth month, it rises half- 
way between the navel and the epi- 
gastrium. In the ninth month, it 
reaches the epigastrium. In the 
tenth month, two or three weeks 
before confinement, the uterus sinks 
s downward and somewhat forward, 
so that its upper level corresponds 
very nearly to that of the uterus in 
the eighth month. 

The fallacy in this mode of des- 
cribing the progress of uterine 
development, as discovered through 
the abdominal parieties, is that 
the navel is not a fixed point, and 
its distance from the symphysis is 
f SLS*t™ S at Various steadily increased up to a late 
period in pregnancy. A more accu- 
rate manner of describing the height of the fundus is followed 
by Spiegelbergf with the following results : 

From the 22d to the 26th week 8J inches. 

From the 22d to the 28th week 10 J inches. 

From the 22d to the 30th week 11 inches. 

From the 22d to the 32d and 33d weeks. 11 J inches. 

From the 22d to the 34th week 12 inches. 

From the 22d to the 35th and 36th weeks 12 J inches. 

From the 22d to the 37th and 38th weeks 13 inches. 

From the 22d to the 39th and 40th weeks 13^ inches. 

The size of the uterus varies greatly in different women at the 
same stage of gestation, but the above average measurements 
are somewhat excessive. From accurate recorded observations 




Size 
Periods of Pregnancy 



* The absurdity of this statement is seen when we compare it with the 
figures given by Dr. Farre, on page 126. 
f " Lehrbuch der Geb," Bd., ii., p. 115. 



SPURIOUS PREGNANCY. 159 

made by the author, the figures which approximate the true 
average more closely are those which follow : 

From the 16th to the 20th week 6 to 6| inches. 

From the 20th to the 24th week 7 to 8 inches. 

From the 24th to the 28th week 9£ to 10 inches. 

From the 28th to the 32d week 10 to 10* inches. 

From the 32d to the 36th week 11 to 11£ inches. 

From the 36th to the 40th week 12 to 12J inches. 

The facts here presented may aid materially, when taken in 
connection with other conditions, in fixing upon the probable 
time of delivery. 



CHAPTEE VL 

Pseudocyesis. 

Pseudocyesis— false, spurious, or phantom pregnancy — has 
been defined by one as a " mental delusion, resulting in a false 
interpretation of bodily sensations, experienced for the most 
part in the abdomen." It may be more justly regarded as 
a delusory conviction of pregnancy, based upon, or giving rise 
to, symptoms which, in some instances, closely resemble those 
of pregnancy. It is not a fleeting notion, but a fixed idea, which 
is sometimes so vivid as not only to cause the woman both to 
misinterpret and to generate symptoms, but also to undergo a 
concurrence of phenomena, presenting striking resemblances to 
real parturition. A similar mental impression may lead a 
woman to believe that she is the subject of an abdominal tumor. 

Care should be taken not to confound spurious pregnancy with 
"false conception," since there is a wide difference between the 
two states, the latter being nothing more nor less than molar 
pregnancy. 

Dr. Matthews Duncan directs attention to the fact that some 
of the lower animals, such as bitches, exhibit signs of spurious 
parturition. Reviewing the subject of pseudo-pregnancy, in his 
terse and lucid manner, he very properly, as we believe, en:- 



160 SPURIOUS PREGNANCY. 

phasizes the thought that distinction ought to be made between 
those cases where there is merely spurious pregnancy, and those 
in which the patient's vivid imagination, strong with the delu- 
sion, carries her to a culmination of the supposed pregnancy 
in fancied or spurious labor. Dr. Reamy mentions a case where 
not only was a midwife kept two nights watching by the bedside 
of a woman who was the subject of phantom pregnancy; but a 
practitioner, doing a large business, actually shared with the mid- 
wife for several hours, the honor of supporting the perineum. 
Both declared that not only were the pains severe, but the peri- 
neum actually bulged from what was supposed to be the foetal 
head. 

Conditions of Development.— The anomaly of spurious preg- 
nancy is observed in women of various ages. Dr. O'Farrall 
mentions a case which occurred in a girl of only thirteen years. 
Dr. Churchill records one which happened in a young lady of 
seventeen.* Sir J. Y. Simpson, who was the first to give a de- 

* The remarkable influence of mind over bodily states, evincing itself in the 
development of physical signs of pregnancy, is so well illustrated in the fol- 
lowing case, reported by Dr. Kearny, that we give it in full: ' : A beautiful and 
refined girl, 20 years of age, from an adjoining State, was placed under my 
charge. She imagined that, on a certain night, specified and clearly designated 
circumstantially to her mother and a married sister, her room had been entered 
by two men, one of whom had chloroformed, and the other ruined her. She 
had read a few days before a false and sensational article detailing the particu- 
lars of a similar atrocity. When I examined her four months after her sup- 
posed pregnancy had occurred, she was pale, anaemic, nervous, amenorrhceal. 
Her countenance was the picture of despair. At times the abdomen was large, 
then decidedly flat. The mammae were swollen, and contained milk. She suf- 
fered from nausea every morning, and was conscious that for the past few days 
she had felt violent movements in the abdomen. The friends were constantly 
in dread that she .might commit suicide. Ferruginous tonics with generous 
diet, bathing, air, exercise, etc., were tried without avail. Her general health 
did not improve, and no argument or assurance could convince her of her de- 
lusion. On every other subject she was perfectly rational. Finally, after five 
months from the date of her supposed pregnancy had elapsed, I took into her 
room a manakin, the articulated bony and ligamentous pelvis, with Schultz's 
obstetrical plates. I, by this means, succeeded in demonstrating to her the im- 
possibility of pregnancy at five months advancement without greater abdomi- 
nal enlargement. I spent in this demonstration at least an hour, going over 
and over the ground. It was in the presence of her mother. Success rewarded 
me. She was convinced of her delusion. The fear never returned. She gained 
eighteen pounds in weight in three weeks. The menstrual function was at 
once established." 



CAUSES OF SPUKIOUS PEEGNANCY. 161 

tailed description of spurious pregnancy, elucidate its causes, 
and prescribe its treatment, thinks the complaint as frequent 
during the first year after marriage, as at any other time. Dr. 
Montgomery believes it to be most frequent at the climacteric 
period. Melancholy instances of the kind have been observed 
in aged spinsters and widows, who had long passed the meno- 
pause, in whom life was rendered intolerable by reason of the 
harrowing delusion. 

Etiology. — The excesses of early married life, and the physi- 
cal and psychical changes incident to such a period in a woman's 
history, afford, in the susceptible, an excellent basis upon which 
to frame a false conviction of pregnancy. The same is also true 
of the disturbed physical and mental equilibrium attendant on 
the climacteric period. It seems clear, also, that a conscious- 
ness in the unmarried of having been exposed to the risk of im- 
pregnation, and the impugnings of a guilty conscience, contri- 
bute to settle and fix the unpleasant delusion. 

The latter may operate as powerful predisponents to the phys- 
ical and mental states and symptoms which point so signifi- 
cantly to a pregnant condition; but it is probable that in many 
instances there is a transposition of cause and effect. In one 
example, the physical symptoms which characterize the case, are 
doubtless the result of a previous mental state, being physical 
expressions and sequences of a settled delusion, while in another, 
the mental impression is, as in real pregnancy, consecutive on 
observed physical conditions. In the latter instance, it is doubt- 
less true that the bodily state is modified in great meas- 
ure by the rooted notion which originated from physical 
phenomena. Dr. Simpson says that " the aggregate of the symp- 
toms which we class under the designation of spurious preg- 
nancy in women, is in some way or other dependent upon the 
changes which occur in the ovaries and in the uterus at the pe- 
riod of menstruation." Another careful observer remarks that 
" it will be found that in most of those persons who fancy them- 
selves pregnant, there is a marked derangement of the circula- 
tory, digestive and nervous systems, either one or all being usu- 
ally implicated." 

Symptoms. — The phenomena observed in spurious pregnancy 
are worthy a careful study. In the majority of cases, there is 
unusual flatulence, and some writers have accordingly attributed 



162 SPURIOUS PREGNANCY. 

the abdominal symptoms manifested, to this circumstance. Simp- 
son does not incline to that view, but regards the phenomenon 
of abdominal distension, as probably dependent " on some affec- 
tion of the diaphragm which is thrown into a state of contraction, 
and pushes the bowels downward into the abdominal cavity." 
There is tympanites; but it is not evident from reported cases 
that either the area of resonance, or the percussion note, differs 
essentially from that often met in the non-pregnant state. In- 
creased prominence of the abdomen, in some cases can be justly 
attributed to deposition of adipose in the abdominal parietes 
and the omentum. 

The movements, which so closely simulate those of the foetus, 
are probably produced in some cases by flatus in the intestines ; 
but they are of tener due to spasmodic muscular action. Dr. B. F. 
Betts relates a case wherein the movements were so vigorous as 
to be discernible through the clothing. Upon examination of 
the abdomen, he found the cause to be spasmodic contraction of 
the rectus abdominis.* 

In some cases the abdomen is swollen to an extreme degree, 
but these are exceptions to the rule. In palpating, the hand 
may meet with resistance, but it generally arises from contraction 
of the broad, flat muscles of that region. In a few reported in- 
stances there has been a certain amount of tumefaction, which 
assumed the outline of a pregnant uterus. 

Pseudo-pregnancy may continue for only a few weeks, and then 
wholly vanish, or it may persist for seven, nine, twelve or even 
eighteen months, — perhaps longer. The similarity of some of 
the manifestations to those of certain nervous disorders of a 
hysterical type, should not be overlooked. The strong mental 
impression, the exaggeration of sensations and conditions, the 
flatulency so often observed, and the state of nervous exaltation, 
are all of this nature. 



* " By an application of the palmar surface of the hands to the abdominal 
walls," says the Doctor, " the recti muscles were found to be irregularly con- 
tracting, so as to appear at first as though they were pressed out by the move- 
ments of a child in utero, at irregular intervals. From an inspection, it was 
impossible to distinguish these contractions from the real movements of a foetus, 
but by palpation, the tendonous attachments of the muscles to the brim of the 
pelvis were felt to be stretched, as from strong muscular contractions." 



DIAGNOSIS OF SPURIOUS PREGNANCY. 163 

Diagnosis. — The diagnosis of pseudocyesis will vary in relia- 
bility according to the period of development which has been 
reached at the time of examination. In early gestation we have 
relative signs only, upon which to base our convictions, and these, 
though in certain combinations they may lead with strong prob- 
ability to conclusions, afford, after all, nothing more than pre- 
sumptive evidence. A notion of existing pregnancy takes pos- 
session of a woman, and she presents herself for diagnosis. 
Gestation, if begun, is two or three months advanced. Some of 
the relative signs of that condition are found, giving color to the 
presumption, but the judicious physician will not express an 
unqualified opinion. On the contrary, there may be an absence 
of the most common presumptive signs of pregnancy, yet an 
unequivocal diagnosis of non-pregnancy would be unwise. At a 
later period a physical examination ought to yield unmistakable 
results. Abdominal distention, due to a tumor of some sort, 
may create in the woman's mind a conviction of pregnancy not 
easily eradicable. Consecutively, symptoms closely resembling 
those of pregnancy may be developed. In such cases the trinity 
of signs pathognomonic of the real condition, namely: fcetal 
movements, ballottement and the fcetal heart-sounds, will go far 
to clear up the doubtful points in the case. 

It is not always possible to make a satisfactory examination in 
a case of doubtful pregnancy, without first bringing the woman 
under anaesthetic influences. When this has been done, since 
by it flatulency will be in great measure overcome, muscular 
spasm subdued, and sensibility annulled, the abdomen will offer 
no resistance to deep palpation, nor the vagina to thorough ex- 
ploration, affording thereby conditions . the most favorable for 
diagnosis. Mention should also be made of the want of sym- 
metry and completeness in the order of development and mutual 
relation of the signs. There is a lack of harmony in the assem- 
blage of the phenomena, an irregularity or defect in the sequence, 
the grouping, or the character of the symptoms, creating in the 
observer an impression unlike that derived from a clinical study 
of the signs of real pregnancy. This is especially true with 
regard to menstruation. Earely is the menstrual function sus- 
pended for nine months. It is also worthy of notice that move- 
ments, inferentially foetal, in many of these cases are felt much 
earlier than in those of real pregnancy. 



EXTRA-UTEKINE PREGNANCY. 

Treatment. — The delusion which enthralls the woman in 
these interesting cases is not always easily removed. If she 
has confidence in her medical adviser, she will be persuaded, 
perhaps reluctantly, to cast away her erroneous notions. It 
may be necessary for him to point out and elucidate the prem- 
ises upon which his conclusions rest, but such an appeal to her 
reason will generally avail. In those cases where the con- 
viction of pregnancy was derived from logical conclusions based 
upon insufficient data, there may not be marked physical im- 
provement, even after the delusion has been dispelled, without 
suitable medicinal treatment. If there was antecedent menstrual 
suppression, Pulsatilla, apis, sulphur, or some^other remedy may 
be required to regulate functional activity in the generative 
sphere. If the digestive apparatus is disordered, china, lycopo- 
dium, nux vomica, mix moschata, or carbo vegetabilis, may be 
needed. Here, as elsewhere, an endeavor should be made to 
ascertain the pathological condition upon which the train of 
symptoms depends and then to seek the similimum of the case 
as a whole, by individualizing as closely as possible. By dis- 
tinguishing between the sequence and dependence of mental 
and physical symptoms, and by the use of rational and medicinal 
means, we may reasonably hope for the best success. 



CHAPTEE VII. 

The Pathology of Pregnancy. 

Extra-Uterine Pregnancy. — Pregnancy has few occurrences 
associated with it, more disastrous in their results, than the 
development of the ovum outside the uterine cavity. After 
coitus, the spermatozoa make their way with a certain degree of 
rapidity through the uterine cavity and Fallopian tubes toward 
the ovaries. Fecundation, as has before been stated, may occur 
at almost any point on the route, in the uterine cavity, in the 
Fallopian tubes, or at the ovaries; the most frequent point of 
contact between the male and female elements probably being 



OYAKIAN AND ABDOMINAL PREGNANCY. 165 

in the outer third of the tubes. After impregnation, the ovum 
may be arrested in its progress toward the uterine cavity, and 
development take place, at the ovary, in the abdominal cavity, 
or in the tube. Accordingly we have ovarian, abdominal, and 
tubal pregnancy, besides some minor varieties, the names indi- 
cating the situation of the developing ovum. 

Ovarian Pregnancy. — Careful observers have put upon rec- 
ord several cases where fecundation and development of the 
ovum took place within the Graafian follicle. When this occurs, 
the follicle may close, and development go on outside the peri- 
toneal cavity, or the ovum may work its way through the aper- 
ture resulting from rupture of the follicle, and thus come even- 
tually to lie chiefly within the peritoneal cavity.* From the 
amount of distension to which the sac is subjected, rupture 
usually takes place within the early weeks of pregnancy. Such 
an occurrence does not always prove fatal to ovular development, 
for the sac walls are sometimes strengthened by adhesions to 
the peritoneum covering adjacent viscera, and gestation goes on. 

False or Tnbo- Ovarian Pregnancy. — When the ovum is 
arrested in the fimbriated extremity of the tube, the cyst struc- 
ture is composed partly of the fimbriae of the tube, and partly 
of ovarian tissue. This makes development less confined, and 
the pregnancy may continue, without laceration, to an advanced 
period, or even to term. This form much more nearly resembles 
abdominal, than ovarian pregnancy. The placenta is usually 
developed in the pelvic cavity. When none of the investing 
structures are ovarian, it is termed iubo-abdominal. 

Abdominal Pregnancy. — The etiology of abdominal preg- 
nancy remains in doubt. It probably arises in some cases from 
the impregnated ovum being dropped directly into the periton- 
eal cavity, in other instances very likely it is a secondary out- 
growth from the tubal and ovarian forms. Dr. Barnes believes 
that it is never primarily abdominal, because of the difficulty of 
conceiving how so small a body as the ovum should be able to fix 
itself on the smooth surface of the peritoneum; but a contrary 
opinion is entertained by most authorities. Some have supposed 
that abdominal pregnancy may originate from impregnation of an 
ovule already lying in the peritoneal cavity, by spermatozoa 

* Puech. Annal. de Gynsec, July, 1878. 



166 



EXTRA-UTERINE PREGNANCY, 



which have found their way thither. From all that has been 
observed, it is highly probable that it is no uncommon thing for 

Fig. 86. 




Abdominal Pregnancy, 
an ovule to fall into the peritoneal cavity, and there, after an 
uncertain time perish, without giving rise to any disturbance. 
But when, from fertilization it does survive, a connective tissue 
proliferation is set up which surrounds the ovum with a vascu- 
lar sac. The latter often attains a thickness nearly as great as 
that of the uterine walls. The chorion villi sprout, form attach- 
ments to the sac, and other structures, and eventually develop a 
placenta. The walls of the sac and the ovum generally develop 
pari passu, and extend into the abdominal cavity, forming ad- 
hesions to the intestines, the mesentary and omentum. 

In unusual cases the ovular development proceeds without the 
formation of pseudo-membranes, the coverings of the foetus 
being only the amnion and chorion. 

Rupture of the foetal coverings sometimes takes place in ab- 
dominal, in ovarian and in tubal pregnancies, and the foetus 
passes into the abdominal cavity. Death of the foetus generally 
follows, but, in other instances, development is continued by 
the formation of a new sac. When foetal death succeeds such 
an accident, the child maybe converted into a lithopsedion, or the 
vascular connective tissue surrounding it may preserve the soft 
structures for years. The precis^ seat of attachment in ab- 
dominal pregnancy varies considerably. The placenta has been 



INTERSTITIAL PREGNANCY. 



167 



found fixed to most of the abdominal viscera, to the intestines, to 

the iliac fossa and to the structures 
within the true pelvis. Its most fre- 
quent site is the retro-uterine space. 

Interstitial Pregnancy.— When 

development of the ovum takes place 
in the uterine portion of the tube, 
the term " interstitial pregnancy," is 
employed. This portion of the tube 
is about seven lines in length. From 
hypertrophy of the muscular walls a 
sac is formed about the ovum, which 
projects from the involved angle of 
the uterus. Ovular development, how- 
ever, is so much more rapid than the 
muscular, rupture generally occurs 
before the fourth month. In one re- 
ported case* the uterine wall did not give way, and the ordinary 

Fig. 88. 




A Lithopsedion. 




Interstitial Pregnancy. 
Vide Speigelbekg, " Lehrbuch der Geburtslmlf," p. 313. 



168 EXTEA-UTEEIXE PEEGXAXCY. 

period of utero-gestation was exceeded by a month, when the 
foetus was removed by laparotomy. 

When the fecundated ovuni is arrested near the outer boun- 
dary of the uterine part of the tube, as development proceeds, 
the tumor escapes mainly into the tube, producing what has been 
called tubo-intersiiiial pregnancy. When development takes 
place on the borders of the uterine cavity, the resulting tumor 
may crowd through the Fallopian opening, and lodge in the 
uterus, only to be finally expelled as in ordinary abortion. 

Tubal Pregnancy. — This is the most frequent form of extra- 
uterine pregnancy, and properly comprises the forms described as 
"interstitial," tubo-ovarian," and "tubo-abdominal." The cause 
of this anomaly is found many times in catarrhal affections of 
the tubes, involving a loss of the ciliated epithelium which cov- 
ers the mucous membrane, and doubtless more or less tumefac- 
tion, with consequent reduction of the calibre of the canal. In 
other cases the ovum may be arrested in its progress by flex- 
ions and constrictions of the tube, resulting from adhesions and 
inflammatory bands. In rare instances it is due to the existence 
of small polypi. In a number of cases the corpus luteum has 
been found in the ovary upon the opposite side from that suf- 
fering from the abnormal development, showing that the ovum 
must have migrated from one side to the other, or that its 
vitality under certain conditions is preserved for a longer period 
than is generally supposed. 

After arrest, the chorion soon begins to develop villi, which 
engraft themselves into the mucous membrane of the tube, and 
serve as anchors to the ovum, and channels for supply of its 
necessary nutriment. The mucous membrane becomes hyper- 
trophied, very much like that of the uterine cavity in normal 
pregnancy, so that a sort of pseudo-decidua results. The pecu- 
liar characters of the mucous lining of the tube afford for the 
ovum but a feeble hold, and hence hemorrhage from lacera- 
tion of the villi can very easily occur. If early rupture does 
not take place, a spurious placenta, wholly of fcetal origin, may 
be said to develop. The villi penetrate to the muscular structure 
of the duct, where they are sometimes surrounded by large 
vessels. The muscular coat of the tube soon becomes hyper- 
trophied, and, as- the size of the ovum increases, the fibres are 
separated so that the ovum protrudes at certain points through 



TUBAL PREGNANCY. 



169 



them, and there it is covered by the stretched and attenuated 
mucous and peritoneal coats of the tube. 

At the beginning of preg- 
nancy the walls of the duct 
are hypertrophiecl, but sub- 
sequently they are 
thinned by the pressure ex- 
erted by the developing 
ovum. Kupture generally 
results within the first three 
months, the site of it being 
at the point of least resist- 
ance, which, in quite a per- 
centage of cases, is at the 
location of the placenta. 
Death usually follows rup- 
ture, either immediately 
from acute internal hem- 
orrhage, or secondarily 
from peritonitis. 

Kupture of both ovum 
and tube walls may take 
place, when the foetus will 
escape into the abdominal 
cavity; there may be rup- 
ture of the tube only, suc- 
ceeded by passage of the 
ovum into the cavity; or, 
finally, there may be a 
more favorable termina- 
tion, in which the ovum re- 
mains in the tube, where Tubal Pregnancy, 
it serves as a tampon, and diminishes the hemorrhage. 

Nature here manifests its conservative tendencies, for when 
maternal death does not speedily ensue after rupture, false 
membranes are formed about the foetus, or the entire ovum, and 
it thus becomes encysted. 

The tube may rupture at a point where it is not covered by 
peritoneum, in which case there is escape of the ovum and 




170 



EXTRA-UTERINE PREGNANCY. 



effusion of blood between the folds of the broad ligament. This 
is known as extra-peritoneal pregnancy. 



Fig. 90. 




Mfm 



Tubal Pregnancy. 

Occasionally tubal pregnancy, from the excessive thickness 
of the muscular walls, goes on to full term. 

Pregnancy in the Rudimentary Cornu of a One-Horned 
Uterus. — The resemblance between this and tubal pregnancy is 
so close that the most careful examination will rarely enable a 
distinction to be made during life. After death, the only cer- 
tain guide is afforded by the situation of the round ligament, 
which, in tubal pregnancy, is between the sac and the uterus, 
and in the rudimentary horn lies outside the sac. Develop- 
ment in a rudimentary cornu does not result in so early a rup- 
ture as in the instance of tubal pregnancy. The point of 
laceration is at the apex of the cornu, where the walls are thin- 
nest. Kceberle* mentions a case wherein foetal death occurred 



* Kgeberle, " Gaz. Hebd ," 1866, No. 34. 



PREGNANCY IN RUDIMENTARY CORNU. 



171 



at the fifth month, and the product of conception was converted 

into a lithopaedion. Turnerf relates one in which pregnancy 

went on to full term. 

Fig. 91. 




Pregnancy in a rudimentary cornu. 

Rarer Tarieties. — Among the rarer varieties is that in which 
the placenta is in a normal situation within the uterine cavity, 
and the foetus within the Fallopian tube. In another form 
the foetus is found in the abdominal cavity, and the placenta in 
the uterus, the two being connected by an umbilical cord run- 

f Turner, " Edinb. Med. Jour.," May, 1866, p. 974. 






172 EXTRA-UTERINE PREGNANCY. 

ning through the oviduct. The latter variety of cases has been 
called the utero-tubo-abdominal. Another rare form is known 
as the sub-peritoneo-pelvic, in which the ovum, from failure or 
inability to get within the tube, slips between the folds of the 
broad ligament, and there develops. 

Uterine Changes in Extra-Uterine Pregnancy. — During 
the development of a foetus outside the uterus, changes, more or 
less marked, have been observed in that organ. They consist 
chiefly in increased vascularity, in marked increase in size, and 
in the characteristic thickening and hypertrophy of the mucous 
membrane. But these symptoms are of short duration, since 
the stimulus essential to their continuance, such as is supplied 
by entrance and implantation of the fecundated ovum, is want- 
ing. Its bulk and vascularity are soon restored to nearly the 
normal standard. 

Symptoms of Extra-Uterine Pregnancy. — In the early part 
of such a state there are few, if any, symptoms, which differ ma- 
terially from those attending normal pregnancy. The woman 
may enjoy health, unsettled only by gastric disturbances so com- 
mon to gestation. Menstruation is interrupted in only about 
fifty per cent, of the cases, though it is finally suppressed in 
most instances, where the condition is not brought to a close by 
rupture of the sac. There is generally some abdominal pain, 
usually constant, but sometimes intermittent, within a circum- 
scribed area. Often previous to rupture, or, in abdominal preg- 
nancies, the death of the foetus, in addition to the other suffer- 
ing, the woman experiences uterine pain of a bearing character. 
In other cases there is very little to attract attention to the case 
until the moment of rupture. As the ovum increases in size, 
some discomfort may arise from pressure, exerted by the tumor 
against other structures. Changes in the breasts and morning 
sickness are of common occurrence. After a time the tumor 
may be felt, which resembles the gravid uterus, but which is 
situated a little to one side of the median line. Quickening and 
the foetal heart-sounds are soon discovered. 

Terminations. — M. Deseimeris, who has written a memoir on 
this subject, states that rupture takes place in more than three- 
fourths of all cases. In tubo-uterine pregnancy it occurs, in the 
main, before the close of the second month; in tubal, in the 



TERMINATIONS. 173 

fourth month; in ovarian pregnancy, later, and in abdominal 
pregnancy not until the eighth or ninth month. The most com- 
mon termination then, by far, is rupture, — rupture of the foetal 
membranes alone in abdominal pregnancy, and of both sac and 
membranes in other forms. 

Rupture is often preceded by the bearing pains alluded to, 
which may continue for hours. These suddenly cease; the tu- 
mor diminishes in size; and then follow yawning, languor, 
fainting, clammy perspiration, rapid pulse, intermittent vomiting, 
collapse, and occasionally acute mania. These symptoms are 
succeeded by death, or, the bleeding being arrested, the woman 
rallies and escapes immediate danger. Still, death may follow at 
an interval of some days, purely as the result of hemorrhage. 
A pretty large percentage of cases survive these perils, and the 
foetus remains, perhaps for years, without bringing about fatal 
results. When foetal death occurs previous to rupture, the ovum 
may undergo a degenerative process by means of which it is 
converted into a mole, or a lithopsedion. In other cases it under- 
goes mummification. 

The immediate dangers of rupture are succeeded by others 
equally grave. As a result of rupture, severe peritoneal inflam- 
mation follows. Should the natural powers withstand this forc- 
ible onset, the results of the inflammation may be accounted 
favorable, inasmuch as pseudo-membranes are formed from co- 
agulable lymph, which exercise a conservative influence by shut- 
ting off the ovum from the peritoneal cavity. In the cases where 
rupture is not followed by peritonitis, Schroeder says the move- 
ments of the foetus within its membranes may give rise to such 
intense suffering as to bring about death from exhaustion. In a 
certain proportion of cases, the foetus dies early, a suppurative 
inflammation in the sac is set up, and death results from general 
peritonitis, or from profuse suppuration. Should the woman 
survive, in consequence of low intensity and meagre extent of 
the action, fistulous openings to other hollow viscera may be 
formed, through which the sac contents may gradually be elimi- 
inated. The opening is extremely liable to be into the large intes- 
tine, sometimes through the abdominal walls, and rarely into the 
vagina and bladder. At best, the process of elimination is 
extremely slow. For weeks or months, portions of the more 
indestructible foetal structures, such as bones and teeth, are dis- 



174 EXTEA-UTERINE PREGNANCY. 

charged. During this discharge of debris the inflammatory- 
action in the cyst goes on, and is probably intensified by the 
admission of air, or the contents of the viscera with which the 
sac communicates. Irritative fever supervenes, and death from 
exhaustion or blood poisoning is a common result. 

Sometimes the before described inflammatory changes do not 
occur, as the result of foetal death, and then the fluid contents 
of the sac are reabsorbed, and the walls collapse. The soft 
tissues of the foetus undergo a species of degeneration, closely 
allied to adipocere. The fluid portions are afterwards absorbed, 
so that the bones, lime lamellae, and incrustations on the walls of 
the sac remain. In other cases the foetus becomes mummified, 
preserving its shape and organs to the minutest detail. A foetus 
which has undergone these changes is called a lithopaeclion, and 
it may remain for years without serious inconvenience to the 
woman. 

Other conditions unite to bring about death, as for example: 
pressure of the tumor upon other structures, giving rise to in- 
tolerable suffering, and interfering with the proper performance 
of organic functions. 

Rupture is sometimes obviated by early death of the ovum. 
In such a case there is retention for a considerable time, without 
hemorrhage, or peritoneal inflammation, but the remains are 
likely to be finally eliminated by a process of ulceration similar 
to that before described. In rare instances there has been 
retention, without great discomfort, for a period of thirty, forty 
or even fifty years. Women in some of these cases have been 
the subjects of repeated pregnancies, terminating in a natural 
manner, without in any way interfering with the extra-uterine 
foetus. 

" If pregnancy goes on without accident or hindrance till the 
close of the period which ordinarily marks utero-gestation, 
pains come on, which are periodic, and which are described by 
women who have undergone normal labor, as precisely similar 
to those attending that process. 'These pains,' says Burns, 
' usually begin in the sac, and then the uterus is excited to con- 
tract and discharge any fluid it contains.' This uterine effort at 
the close of the ninth month, is a physiological fact of surpass- 
ing interest." 

Diagnosis. — In the diagnosis of extra-uterine pregnancy, there 



DIAGNOSIS OF EXTRA-UTERINE PREGNANCY. 175 

are three points to be established: 1. The existence of the 
common signs of pregnancy. 2. The emptiness of the uterine 
cavity, and 3. The presence of a tumor in close contiguity to 
the uterus. Diagnosis is attended with much difficulty, and the 
best practitioners have been deceived. 

The diagnosis of abnormal pregnancy, especially of the tubal 
variety, is a matter of great and increasing importance, since 
modern surgery has made it possible to avert the almost certain 
death which awaits the patient. But the symptoms are obscure, 
and m only a small percentage of cases are suspicions aroused 
concerning the normal character of the pregnancy till rupture 
suddenly occurs. The existence of a hemorrhagic discharge, 
appearing after the eighth week, is of some significance. There 
are also paroxysmal pains, radiating from one iliac fossa, which 
are often attributed by the woman to flatulent distension of the 
intestines, and thus pass from notice. If then we meet a case 
presenting the symptoms of early pregnancy, in which there is 
irregular hemorrhagic discharges, accompanied by abdominal 
pain, our suspicions would justify a demand for a careful exam- 
ination, when the real nature of the case may be discovered. 

A vaginal examination made at such a time would reveal the 
uterus somewhat enlarged, its cervix slightly softened, and the 
existence of a peri-uterine tumor. When situated low, the use 
of conjoint manipulation will enable one to make out the form, 
and feel the fluctuation in the sac. In the absence of peritoneal 
adhesions, ballottement of the entire tumor can be made out. 
Ballottement of the foetus can be detected by the end of the 
fourth month. There are various conditions which give rise to 
physical signs of a similar kind, such as small ovarian and fibroid 
tumors, or even hasmatocele, and hence the difficulty of differ- 
ential diagnosis.* 

In view of the desirability of early recognition of extra-uterine 
pregnancy, it is justifiable, when the other evidence in favor of 

* A curious example of the difficulties of diagnosis is recorded by Joulin, iu 
which Huguier, and six or seven of the most skilled obstetricians of Paris, 
agreed on the existence of extra-uterine pregnancy, and had, in consultation, 
sanctioned an operation, when the case terminated by abortion, and proved to 
be a natural pregnancy. 

Vide Playfair. " System of Midwifery," p. 173. 



176 EXTRA-UTERINE PREGNANCY. 

the condition is strong, to pass the uterine sound to demonstrate 
the absence of intra-uterine development. 

When rupture of the sac occurs early in pregnancy, the flow 
of blood may be moderate, and the physical signs be only those 
of ordinary hsematocele. Later rupture gives rise to symptoms 
of extensive internal hemorrhage, and, as a rule, is speedily fol- 
lowed by death. 

In abdominal pregnancy the form of the abdomen will be 
observed to differ from that of normal gestation, it being gener- 
ally more developed in the transverse direction. In the latter 
months, the form of the foetus can be felt with remarkable dis- 
tinctness. The cervix is somewhat softened, but often displaced, 
and sometimes fixed by peri-metric adhesions. Conjoint touch 
may enable the examiner to feel the uterus distinctly separate 
from the bulk of the tumor, and demonstrate its nearly normal 
non-pregnant size. 

When extra-uterine pregnancy goes beyond the fourth month 
without occurrence of rupture, with rare exceptions, either an 
ovarian or abdominal pregnancy may be assumed to exist. 

A means of diagnosis of considerable value is based upon the 
contractility of the uterine muscular fibre in response to stimu- 
lation. If extra-uterine pregnancy exists, friction with the hand 
over the tumor will excite contractions in the uterus, which have 
no effect on the size or form of the tumor itself. 

As a final mode of examination in doubtful cases, the woman 
may be anaesthetized, and deep and thorough bi-manual manipu- 
lation resorted to. Under such conditions the finger may be 
passed into the uterine cavity, into the rectum or into the blad- 
der,* the risk being assumed by the physician, of its proving to 
be a case of uterine pregnancy, and its resulting in miscarriage. 

Treatment. — The mode of treatment will be determined 
largely by the degree of development which has been attained, 
the condition of the foetus, and the health of the woman. For 
the sake of perspicuity and convenience, we make three classes 
of cases, viz. : 1. Those which have not advanced beyond the 
limits of a few weeks. 2. Those wherein gestation is well ad- 
vanced, and the foetus is still living. . 3. Those in which preg- 
nancy has been prolonged after foetal death. 

*Dr. Ngeggerath. "Am. J. Obs.," May 1875. 



TREATMENT OF EXTRA-UTEKINE PREGNANCY. 177 

1. Cases of Recent Impregnation. — It lias been observed 
that, when, from any cause, embryonic life is destroyed, recov- 
ery often ensues. Following this hint, it has been proposed as 
a mode of treatment to adopt measures which will compass this 
result. This has been done in some cases with good results, and 
the methods employed were puncture of the sac, injections of 
morphia, and other solutions, elytrotomy, and the induced cur- 
rent. 

Puncture of the Sac is generally effected by introducing an 
exploring needle, a trocar or an aspirator needle, through either 
the vaginal or rectal wall, and drawing off the liquor amnii. The 
results of this mode of treatment have not been wholly satisfac- 
tory, and fatal effects have several times been produced. In 
most of the cases, if not in all of them, however, an ordinary tro- 
car was employed, which necessarily admitted air. We can 
hardly believe that a small aspirator needle could produce serious 
results. Numerous instances of recovery have been put on 
record. 

Injections into the Sac. — Joulin * was the originator of this 
method, and he proposed injections of sulphate of atropia. 
Friedreich afterward following the suggestion with success. 
Morphia was subsequently employed by him with more satisfac- 
tory results. The site of puncture is the abdominal or the vaginal 
walls. When the needle has once entered the sac, a few drops 
of the liquor amnii are withdrawn and their place supplied by 
the solution of morphia. The operation should be repeated 
every second day, until evidences of success are discernible. 

Elytrotomy. — Dr. Gaillard Thomas f opened a cyst from the 
vagina by means of an incandescent platinum knife connected 
with a galvano-cautery apparatus. Through the opening made 
by the knife the foetus was removed, and in attempting to extract 
the placenta, hemorrhage was set up which was controlled with 
the greatest difficulty. Septicaemia followed, but the woman sur- 
vived. Dr. Thomas, in the last edition of his work on Diseases 
of Women, recommends to cut through the sac with Paquelin's 
cautery knife, remove the foetus, but allow the placenta to re- 
main, and then fill the sac with antiseptic cotton, which should 

* Joulin. " Traits complet des accouchements," p. 968. 
f New York Med. Jour., June, 1875. 



178 EXTRA-UTERINE PREGNANCY. 

be removed every thirty-six hours. The operation is designed, 
however, only for cases which, from the severity of their symp- 
toms, demand immediate action. 

The Use of Electricity. — The induced current passed through 
the ovum is a safe and effective mode of destroying the embryo. 
One pole of the battery should be passed into the rectum, against 
the tumor, and the other placed two or three inches above Pou- 
part's ligament, on the abdominal wall. The full force of an 
ordinary battery of a single cell, employed for a few minutes, at 
intervals of twenty-four hours, for several days, will effect the 
purpose. 

When rupture of the sac takes place, treatment should have 
for its object the arrest of internal hemorrhage, and the removal 
of the effects of shock. If the vital forces of the woman are 
not too low, an ice-bag may be applied to the abdomen. Very 
hot applications will answer better in case great depression ex- 
ists. Compression of the aorta, and a sand bag upon the abdo- 
men over the site of the ovum, have also been recommended. 
The patient should be placed in a cool, quiet place, stimulants in 
small quantities administered and often repeated, if required, 
and, in the absence of other special indications, china given. It 
will be a wise policy to follow these with several doses of aconite, 
in anticipation of the peritoneal inflammation which is likely to 
ensue. 

Laparotomy. — Since rupture of the tube is attended with 
fatal results in the vast majority of cases, Kiwisch and others 
have advised abdominal incision, and ligature of the bleeding 
vessels, removal of the sac, and clearing of the peritoneum. 
Still, the operation has not yet been performed, and the expec- 
tant plan of treatment prevails. 

2. Cases of Advanced Gestation, the Foetus Still Living. — 
Most women suffer during the progress of such an abnormal 
gestation, with severe, but brief attacks of peritonitis, from great 
sensitiveness to f cetal movements, from recurring uterine hemor- 
rhages, and from emaciation and depression of the vital powers. 
With the occurrence of labor-like efforts, peritonitis is apt to be 
excited. In view of all the dangers to which both the woman 
and child are exposed, under the expectant plan of treatment, it 
has been proposed that an operation be performed early, with a 
view to rescuing the latter from certain death, without adding to 



TKEATMENT OF EXTRA-UTERINE PREGNANCY. 179 

the risks sustained by the former. But the results of such ope- 
rations have been of a disheartening nature. The chief source 
of danger is found in the hemorrhage which necessarily follows 
removal of the placenta. On the other hand, when the placenta 
is permitted to remain, septic poisoning and fatal hemorrhage 
are liable to occur during the process of elimination. The diffi- 
culties are made still more formidable by the situation of the 
placenta, in a considerable percentage of cases, on the line of 
incision. 

3. Cases of Gestation Prolonged After Death of the 
Fcetus. — When the foetus is dead, no attempt should be made 
to remove the product of conception during the existence of labor 
pains, as the dangers would be thereby unnecessarily enhanced. 
It is generally thought advisable to wait, carefully watching the 
patient, until the symptoms become grave, or there is positive 
indication of the channel through which elimination of the foetus 
is about to take place. The latter will be shown by bulging of 
the cyst in or about the vagina. An opening may be effected by 
the natural efforts, in which case it may be artificially enlarged 
to a size which will admit of f cetal exit. Should the opening be 
into the intestines, the dangers and difficulties attendant on ex- 
pulsion are so great that gastrotomy would be justifiable. 

It is obvious that the presence of a dead fcetus seriously com- 
promises the safety of the woman, and the suppurative process 
which is liable to ensue, inevitably reduces her to a deplorable 
condition. In view, then, of the success which has attended 
secondary laparotomy, on one hand, and the extreme dangers of 
waiting, on the other, operative interference seems to be a justi- 
fiable procedure. Out of thirty-three cases collected by Litz- 
mann, twenty-four of which were between 1870 and 1880, there 
were nineteen recoveries. It will be observed that the two great 
dangers which attend the primary operation (that made during 
f cetal life) — hemorrhage and septicaemia, — are in this operation 
greatly modified, the former by gradual thrombosis and oblit- 
eration of the maternal vessels which follow the cessation of the 
foetal circulation, and the latter by the possibility here afforded 
for the removal of the entire ovum, or the speedy subsequent 
separation and extraction of the placenta. 

With respect to the time for the performance of secondary 
laparotomy, a clear idea is of much importance. The time of 



180 MISSED LABOR. 

foetal death should be carefully noted, and our object should be 
to delay a sufficient length of time to provide for obliteration of 
the placental vessels. Schroeder removed the placenta without 
loss of blood three weeks after cessation of foetal movements. 
DePaul operated four months after foetal death, and lost his 
patient from placental hemorrhage. There is no doubt that the 
process of obliteration of the placental vessels is rapidly effected 
in some, and slowly in others, and hence, under the circum- 
stances, when we can delay, it is advisable to postpone opera- 
tive measures, and treat the patient symptomatica.!] v. The woman 
should receive an abundance of fresh air and nourishing food, 
while in the absence of more specific indications arsemcum 
ought to be administered. Should marked septic symptoms be 
developed, they should be regarded as a signal for interference, 
as delay would certainly be fatal. 

The operation itself should begin with an incision along the 
linea alba, as in other cases. If no adhesions are found between 
the cyst and surrounding structures, it should be turned out 
through the incision, before rupture, and stitched to the cut 
borders of the abdominal wall. The placenta, unless it occupies 
the site of the incision, or unless it separates at once spontane- 
ously, should be permitted to remain. The cord should be 
placed in the lower part of the wound, which will be left open 
for it, and for antiseptic injections. 

Gestation in a Bi-lobed Uterus. — The history of these cases 
corresponds so closely to that of tubal pregnancy, as to require 
but little notice. As elsewhere stated, they cannot be differen- 
tiated during life, and only by careful examination post-mortem. 
The chief difference in their clinical history is, that in cornual 
pregnancy rupture generally occurs a little later than in 
tubal, on account of the greater distensibility of the part. 

Missed Labor. — "An extremely rare and curious phenome- 
non has been occasionally observed, in which the foetus remain- 
ing in utero, labor has not come on at the usual time, and the 
remains of the foetus may be retained for a considerable period, 
or discharged piecemeal by the vagina without, for a time, at 
least, seriously affecting the health of the mother." This has 
been called "missed labor.'" 

For the most part, death of the foetus is followed either by 



MISSED LABOB. 181 

premature expulsion, very soon after life is extinct, or by the oc- 
currence of abnormal development of the fcetal envelopes, and a 
perversion of the natural energies, culminating in molar preg- 
nancy. In the rare cases above alluded to, neither of these oc- 
currences is observed, but the foetus becomes mummified, or dis- 
integrated, and its remains are retained in utero for months, or 
even years. The cause of this is supposed to be absence of 
uterine irritability, obstructed labor, and unusually close adhe- 
sions of the placenta. In many cases uterine expulsive action 
is set up, but, after a time, it ceases permanently, or is renewed 
at intervals, for days, weeks, or even months. Whenever the 
ovum perishes and is kept in the womb for a time far in excess 
of the period of normal utero-gestation, whether molar changes 
take place, the foetus is disintegrated and discharged piecemeal, 
or becomes mummified; indeed, whether any decided post-mor- 
tem changes take place or not, they constitute an instance of 
missed labor. Manget* reports an observation by Langelott of 
a case in which the foetus perished in the fifth month, and was 
not expelled until the twelfth month, in a mummified condition. 
Johnsf observed two cases in which the foetuses died at the sixth 
month, and were not born till five and six months respectively 
after their death. Olshausen J reports a case of retention of a 
mummified three months' foetus for eight-and-a-half months. 
McMahon § relates a case in which a foetus of four months was 
retained for eighteen months, and was then expelled, inclosed in 
a compressed placenta which evidently had continued growing 
for some time after foetal death. The calcified or mummified 
foetus is said to have been retained many years. Foetal bones 
have been discharged from the uterus years after conception. 
A. Halley and H. Davis report the case of a woman who, in the 
second half of her pregnancy, had a brownish discharge from 
the vagina, and occasionally lost putrid fleshy masses, at times 
accompanied with bones. Four years later the os uteri was ar- 
tificially dilated, and eighty-six bones removed in two sittings. 
In rare cases of prolonged retention, the foetus becomes the seat 



* Bibl. Med. Pract., B. iii. Geneva, 1696, p. 814. 

f Dubl. Quart., J. Aug , 1855, p. 63. 

t Berl. Klin., W. 1871, No. 1. 

§ Med. Chir. Review, No. 89, Jan., 1870, p. 278 



182 ABORTION. 

of fatty and calcareous degeneration, in which case it is desig- 
nated by the term lithopsedion. 

Treatment. — When a woman, who has presented the rational 
signs of pregnancy, passes by the period of mature gestation, 
and evinces indications of foetal death, followed by disintegra- 
tion or mummification, it is clear that something ought to be 
done to effectually rid the system of the depressing influences to 
which it is subjected. This can be done only by securing thor- 
ough uterine evacuation. Measures which might answer admi- 
rably in ordinary pregnancy to accomplish the purpose, such as 
Kiwisch's douche, would very likely here prove unavailing. The 
operator should accordingly begin by passing a small sponge or 
laminaria tent into the cervical canal, followed after a time by a 
larger one, and finally, if necessary, by several. When the os 
has thus been opened, he should proceed much as he would 
in abortion, using, from preference, his fingers, but, if necessary, 
the placenta forceps or small blunt hook, as a means of extrac- 
tion. If putrid masses be taken away, the uterus, after complete 
evacuation, may be washed out with a mild antiseptic solution. 
This operation, like all others, ought to be performed through- 
out under antiseptic precautions, and followed with a few doses 
of arnica. 



CHAPTEE VIII. 

The Premature Expulsion of the Ovum. 

Premature expulsion of the product of conception may take 
place at any moment prior to the time when the foetus presents 
all the evidences of maturity, and the process has received dif- 
ferent designations according to the stage of pregnancy at which 
it occurs. Interruption of pregnancy during the first three lunar 
months * is termed abortion; during the fourth, fifth, sixth and 
seventh month, that is, from the time when the placenta is fully 
formed to the date of viability, it is called miscarriage, and 

* Some say, during the first four lunar months. Vide Leishman, p. 357. 



CAUSES OF ABORTION. 183 

from that time to the close of the thirty-eighth week it is known 
as premature labor. While these are the technical , distinctions, 
the terms abortion and miscarriage are used interchangeably by 
many, and, as we conceive, with perfect propriety. 

The term Foetus, according to usage, is not applicable to the 
product of conception until the termination of the third month 
of gestation. Till then it is known as the Embryo. 

The liability to premature expulsion is doubtless greater in 
the early weeks of gestation, when the union between the chorion 
and decidua is imperfect, as hemorrhage is apt to occur and fill 
the space between them, thereby cutting off communication be- 
tween the mother and child. 

Obstetrical writers do not agree as to the relative frequency of 
abortion. Hegar reckoned one abortion to every eight or ten 
full-time deliveries, while Devilliers sets them down in the pro- 
portion of one to three or four. The statistics of Whitehead 
show a proportion of about one to seven. Probably thirty-seven 
out of every hundred mothers experience abortion before they 
attain the age of thirty years. 

Predisposing Causes of Premature Interruption of Preg- 
nancy. — The causes of abortion, miscarriage and premature 
labor, are, in the main, of slow, but cumulative action. The 
way is usually prepared, either by changes gradually effected in 
the ovum, or by certain pathological states of the maternal organ- 
ism. Insidious agencies having finally undermined the vitality 
of the ovular structures, and rendered insecure the placental 
attachments, circumstances which would otherwise have been 
positively innocuous, are then sufficient to precipitate premature 
efforts at expulsion. 

In the study of the etiology of abortion it becomes obvious 
that cause and effect are not always clearly discernible. It seems 
certain, however, that, in some cases, disease of the chorion leads 
the way to foetal death, while in others, chorion changes are con- 
sequent on that occurrence. 

Death of the foetus may be due to direct violence, such as 
kicks and blows upon the abdominal walls; to indirect violence, 
as falls, or strains; to disease of the foetal appendages; to dis- 
eases of the decidua, especially those which induce hemorrhage ; 
to febrile affections; to plethora, or, on the other hand, anaemia. 
In times of famine, great numbers of women abort. Death of 



184 



ABOKTION. 



the foetus is followed sooner or later by expulsion of the uterine 
contents. In the early weeks, delay in some cases results in 
dissolution and absorption of the embryo. Foetal death is 
usually followed by atropy of the villi, and fatty degeneration 
of the placenta. The ovum is thus rendered a foreign body, and 
after the lapse of a certain length of time, which varies largely, 
contractions of the uterus are excited. Before formation of the 
placenta, the ovum is frequently expelled without rupture. Sub- 
sequently, such an occurrence is rare. When the membranes 
give way, and the pressure upon the inner surface of the uterus 
is removed, hemorrhage, more or less profuse, usually follows, 
and continues until complete evacuation has been effected. 

Abortion often finds its predisposing causes also in changes in 
the decidua alone. Among these are: 1. Atrophy, and 2. Hy- 
pertrophy of the uterine mucous membrane. 



*mGB&£3bs&** 



1. Atrophy of tlie Uterine Mucous Membrane. — The endo- 
metrium instead of affording a generous reception to the im- 
pregnated ovum, and snugly enclosing it, in some cases spreads 
an abnormally small decidua serotina, with the result of a small 
placenta. In other cases the decidua reflexa is not completed, 
Fig. 92. or may utterly fail of de- 

velopment, in which case, 
covered only by the cho- 
rion, the ovum is suspend- 
ed from the serotina. 

In either case, the ovum, 
instead of being at once 
expelled by the uterine 
contractions, may be forced 
downwards to the cervix, 
and there remain for a 
time nourished by the ped- 
icle which it forms. This 
has received the name of 
cervical pregnancy. It is 
chiefly the rigidity of the 
os internum, and the cer- 
vix, which retains the ovum, and hence it is an occurrence more 
common in primiparse than in multiparse. In some instances^ 




Ovum with imperfectly developed decidua. 



CAUSES OF ABORTION. 185 

however, the strength of the pedicle is sufficient to prevent 
further descent, even when the os is patulous. 

2. Hypertrophy of the Uterine Mucous Membrane. — En- 
dometritis with consequent thickening of the mucous membrane 
is a frequent cause of abortion, from the fact that it gives rise 
to affections of the placenta. A placenta thus involved may fail 
to supply to the foetus requisite nourishment, or the weakened 
vessels of the decidua may rupture and produce sanguineous 
effusions between the membranes. In retroversion, which is 
recognized as a common cause of abortion, the endometritis is 
probably the chief factor in bringing about the untoward result. 

Eigidity of the uterine walls, as from the presence of intra- 
mural fibroids, preventing proper expansion, may excite efforts 
at abortion. Expansion may also be hindered by peritoneal ad- 
hesions, or the changes which result from pelvic cellulitis. 

In many cases it is impossible to trace the cause of the occur- 
rence to any abnormal conditions of either the foetus and its 
envelopes, or the maternal generative organs. In such women 
there doubtless exists a condition of nerve irritability, which 
readily reflects irritation, proceeding from physical or psychical 
sources, with force sufficient to produce powerful premature 
uterine action. 

Immediate Causes of Abortion. — The immediate causes of 
abortion arise, in general, from the maternal side. No changes 
in the ovum, save those of forcible separation of the ovum from 
its attachments, or rupture of its membranes, could scarcely 
bring about the result. The maternal influence, however, is 
strong and unmistakable, and is often exerted, willingly or un- 
willingly, with the effect to interrupt pregnancy. 

Hyperemia of the Gravid Uterus. — This is probably the 
most frequent proximate cause of abortion. In those cases 
wherein influences have been silently at work to weaken the re- 
lations between the ovum and decidua, any circumstance which 
is capable of determining an unusual quantity of blood to the 
organ, is capable of causing extravasation, separation, and pre- 
mature expulsion. Hyperemia excited by an accomplishment of 
the menstrual cycle, fevers, inflammation of the genitalia, ex- 
cesses in coitus, hot foot-baths, the Use of certain drugs, unusual 
physical exertion, valvular heart-lesions, obstructions to the 



186 ABOETION. 

pulmonary or portal circulation, may one and all lead to rupture 
of the decidual vessels, and consequent extravasation of blood. 
Under conditions of uterine hyperemia, a very slight motion or 
jar, vomiting, coughing and straining, to say nothing of falls, 
injuries, and violent emotions, are capable of precipitating the 
fall of the unripe fruit of the womb. 

The significance of pre-existing remote causes, associated with 
accidental occurrences, is clearly shown in many recorded cases. 
When the connections between decidua and ovum have not been 
weakened by the occurrence of any of the changes before men- 
tioned; in other words, when the woman in all her generative tis- 
sues is in a healthy state, most powerful influences of a baneful 
nature are often suffered, without interruption of a normal course 
of gestation. Falls from considerable heights, giving rise to se- 
vere contusions and fractures, have repeatedly occurred to preg- 
nant women without causing abortion. Dr. Pagan* tells of an 
instance in which his coachman drove directly over a woman 
who was in the eighth month of pregnancy, inflicting upon her 
serious injuries, and still gestation proceeded in a regular man- 
ner to term, and terminated in the birth of a healthy child. M. 
Gendrin f speaks of a young lady who was thrown from a chaise 
over the horse's head, by the animal falling in his career. The 
lady was then five months pregnant, but the accident did not pre- 
vent her from reaching her full term. Cazeaux met a case pre- 
cisely similar in the wife of a notary living near Paris. Some 
women, with the desire to rid themselves of a developing ovum, 
resort to most desperate measures without success. Physicians, 
without a knowledge of existing pregnancy, have passed the uter- 
ine sound, and swept it about in the uterine cavity, and have even 
introduced and left an intra-uterine stem pessary, without produc- 
ing premature expulsion. J 

Symptoms of Abortion. — Early abortions may, and doubtless 
do occur, in many cases, with symptoms differing but little from 
those attending a return of the monthly flow. There is some 
pain in the sacral and hypogastric regions, and bearing sensa- 
tions in the pelvis, with a rather free flow of blood, when the 

* Vide Leishman, " System of Midwifery," p. 362. 

f Vide Cazeaux, " Theoretical and Practical Midwifery," Am. Ed., p. 567. 

JPlayfaik; "'System of Midwifery," Am. Ed., p. 240. 



SYMPTOMS OF ABORTION. 187 

whole ovum may be discharged, enveloped in a clot, and thus ut- 
terly escape notice. Oftener, however, the ovum is broken, and 
the liquor amnii is lost before expulsion. The embryo follows, 
and ultimately the secundines, the latter when opened some- 
what resembling the placenta of later pregnancy. In either case 
there is generally but a moderate loss of blood; but the rule is 
not without its exceptions. In a certain proportion of instances, 
even in the early weeks of pregnancy, the hemorrhage attendant 
on the occurrence is remarkably profuse, and occasionally even 
alarming. Still the practitioner may comfort himself and patient 
with the reflection that this symptom is more alarming than dan- 
gerous, since women who are the subjects of it not only survive, 
but rarely suffer serious impairment of health or strength. 

As soon as the ovum, whether whole or in fragments, has been 
completely extruded, there is usually an end to the bleeding, and 
but a short period of time is consumed in involution. But in 
early, as well as in later abortion, the presence in utero of any 
part of the product of conception whether embryo, or envelopes, 
is apt to continue the hemorrhage. There may be temporary 
cessation, but the flow again returns to declare that the abortive 
process is incomplete. 

Later Abortions present more pronounced characters. The 
pains are more severe, the flow more profuse, and the effect on 
the woman more profound. For some time before these symp- 
toms set in, prodroma are generally experienced in the shape of 
fullness and weight in the pelvis, sacral pains, frequent micturi- 
tion, and a mucus or watery discharge. These, followed by re- 
current pains and hemorrhage, indicate a threatened abortion. 
There maybe but a slight discharge at anytime during the pro- 
gress of the case, but in every instance there is liability to ex- 
hausting and even dangerous hemorrhage. There is probably 
little real peril to life, but the baneful effects of sanguineous de- 
pletion are not speedily remedied. The tenor of the woman's 
general health may be seriously impaired for months, or even 
years. 

In a typical case of abortion occurring about the third month, 
the ovum is extruded without rupture, in which case it passes 
into the vagina, covered by the decidua vera, or drags the in- 
verted decidua after it. The uterus then being empty, contracts 
down, and the hemorrhage is at an end. A small afterbirth, with 



188 ABOKTION. 

shrunken umbilical vessels, is usually found. In abortions oc- 
curring after the third month, it is uncommon for the ovum to 
come away entire; but the membranes are ruptured, the foetus 
expelled, and the secundines are retained. During the period of 
retention, which may be prolonged, the woman is in constant 
danger of profuse and sudden flow. After the abortive act has 
been finished by complete evacuation of the uterus, hemorrhage 
is an unusual occurrence. In rare cases, owing to a depraved 
state of the system, to intra-uterine growths, or to imperfect in- 
volution, it becomes an annoying complication of the puerperal 
state. 

Incomplete Abortion. — Ketained secundines, whether in 
early or later abortion, are apt to prove a source of much trouble. 
Here, as in labor at full term, after expulsion of the foetus the 
uterus is disposed to take a season of rest; but, unlike the latter, 
this rest is usually prolonged. We may sometimes vainly wait 
hours or days for renewed action, while cases are by no means 
rare in which vigorous uterine contractions never return. 

The comparative comfort of the woman will lead her to believe 
that the process is complete, and a physician may not be con- 
sulted until serious symptoms are developed. Violent hemor- 
rhage may at any time ensue, or in default of that, septicaemia 
may be set up. In many cases the physician does not reach his 
patient until the foetus has been expelled, and the clots which 
generally follow are assumed to be the afterbirth. In that case 
he is informed that everything has come away, and as the evi- 
dence has been destroyed, the intelligence of the attendants is 
given undue credit. Skepticism is here commendable. The phy- 
sician ought to institute a thorough exploration, if it can pru- 
dently be done, or he should act on the theory of partial reten- 
tion. 

The Diagnosis of Incomplete Evacuation becomes a point 
of great nicety, as well in those cases where the extruded mat- 
ters have all been preserved, as in those where they have not. 
When the ovum is discharged with its entire membranes intact, 
it is not difficult to arrive at a positive conclusion, but, in abor- 
tions after the third month, this does not often occur. The pla- 
cental or decidual mass is relatively large. The size of the em- 
bryo may be represented by the last phalanx of the little finger, 
or a Lima bean, while the afterbirth, when spread out, is as large 



MEMBRANES EXPELLED — FCETUS RETAINED. 189 

as half the hand. In some cases the secimdines are expelled or 
extracted in fragments, and a retained portion is easily over- 
looked. Absolute certainty can be attained only by a careful ex- 
ploration with the finger. 

The sensations experienced by the woman have some diag- 
nostic value. These are of a nervous kind, and are felt most 
noticeably about the head. It is a species of nervous erethism, 
beyond the power of description, attended with some headache, 
and a general unrest. These symptoms usually persist until full 
evacuation of the uterus has been accomplished. 

The existence of hemorrhage, especially when it occurs in 
small or large gushes, is a further indication of incomplete evac- 
uation. 

Membranes Expelled, — Fcetus Retained. — Cases are on rec- 
ord in which the order of expulsion was reversed. The mem- 
branes were ruptured and expelled, uterine action ceased, and 
the foetus was retained. Dr. Noeggerath* mentions a case in 
which the membranes were expelled at the fourth month of preg- 
nancy, and the foetus was retained for several weeks. In the 
interval between expulsion of the membranes and birth of the 
foetus, the woman was in a comfortable state. Dr. Chamberlain f 
relates a case in which the membranes were expelled, but the 
foetus continued in utero for twelve weeks. Dr. Peaslee had 
a similar case in which the foetus tarried three months. In the 
last two cases the women manifested symptoms of retention of 
a part of the ovum, there being hemorrhage and irritative fever. 

The following observations by Spiegelberg J concerning in- 
complete abortion, merit most attentive study: 

1. Most frequently hemorrhage continues at intervals, sponta- 
neous elimination gradually taking place as, through retrograde 
changes, portions of the retained membranes become successively 
loosened in their attachments to the uterus. 

2. In exceptional cases the hemorrhage ceases for a time en- 
tirely. For days, weeks, and even months, the woman appears 
quite well; then suddenly, strong contractions, accompanied by 
profuse hemorrhage, usher in the elimination of the foetal de- 

* Am. Jour. Obs., vol. iv., p. 551. 
f Am. Jour. Obs., vol. iv., p. 552. 
X Vide Lusk. " Science and Art of Midwifery," p. 296, 



190 



ABORTION. 



pendencies. Lusk says, in a case of his own, three months 
elapsed from the occurrence of the first hemorrhage, which took 
place toward the end of the third month, and was quite insig- 
nificant in amount, before the abortion was completed. Mean- 
time, as there were progressive abdominal enlargement, supposed 
quickening, and milk in the breasts, the threatened abortion was 
believed to have been arrested. Total retention, with a long 
interval of repose, is thought to be due to complete adherence of 

Fig. 93. 




Uterus, with basis of a fibrinous polypus after an abortion. (Frankel.) 



the placenta, which continues to receive nutrient supplies from 
the uterus. He believes that a menstrual period is the usual 



INCOMPLETE EXPULSION OF TWINS. 191 

time at which the discharge of the retained membranes takes 
place. 

3. Of more frequent occurrence than the foregoing, is the pu- 
trid decomposition of the retained portions. It occurs chiefly 
in cases where there is more or less complete loss of organic 
connection between the placenta and the uterus. Decomposition 
of the non-adherent portions is produced by the introduction of 
air during the escape of the embryo, or through the subsequent 
passage of the finger into the uterus, or where portions of the 
ovum hang down into the vagina, by absorption of septic matter 
from the vagina upward into the uterus. As a result of putrid 
decomposition, the woman is exposed to septicaemia, and infec- 
tion of thrombi at the placental site. Fatal results are, however, 
rare, as decomposition is usually a late occurrence, setting in, as 
a rule, only after protective granulations have formed upon the 
uterine mucous membrane, and after the complete closure of the 
uterine sinuses. Continued fever, with intercurrent attacks of 
hemorrhage, is, however, set up, but passes away finally with the 
gradual discharge of the decomposed particles, while the threat- 
ening symptoms subside. Still, now and then septic processes 
lead to an unfavorable termination. Local perimetric inflamma- 
tion is a common event. 

4. Where there is a certain degree of relaxation with enlarge- 
ment of the uterine cavity, the fibrin of the extravasated blood 
may become deposited about any uneven surface within the 
uterus, and give rise to a polypus-shaped body, suggestive in its 
mode of development of the stalactite formations in calcareous 
caverns. These so-called fibrinous polypi generally develop 
around the debris of an abortion, such as retained bits of decid- 
ua, placental remains, and portions of the foetal membranes. 
In some cases likewise, thrombi projecting from the placental 
site become the base of a loose fibrinous attachment. Placental 
polypi give rise ultimately to bearing-down pains, and intercur- 
rent hemorrhages. They may even decompose, and endanger 
life by septic absorption. 

Expulsion of One Foetus in Twin Pregnancy.— In twin 
pregnancy one ovum may be blighted and expelled, and the other 
retained till completion of the full term of utero-gestation. A 
most interesting case of this kind was reported by Dr. E. Che- 



192 ABORTION. 

nery.* A woman at the fifth month presented the usual symp- 
toms of abortion, and a foetus in its envelopes, together about 
the size of a common open-faced watch, was expelled. Upon 
making a vaginal examination the head of a much larger foetus 
was found protruding through the os uteri. This was seized by 
the fingers for the purpose of extraction, but escaped and re- 
turned to the uterine cavity. The physician supposing that 
expulsion was then a necessity, gave ergot, but the os contracted, 
and the uterus refused to act. When the full term of pregnancy 
was accomplished, expulsion took place in a normal manner. 
Other cases are on record. In general, however, in multiple 
pregnancy, the uterus is entirely evacuated without a long inter- 
val of repose. 

Diagnosis. — Contemplation of the symptoms of abortion as 
related would lead one to suppose that diagnosis of the approach- 
ing occurrence should not be attended with much difficulty. 
Still, in many cases this is not true. The woman, perhaps, has 
evinced her pregnant state by the usual symptoms, and now 
hemorrhage and pain indicate its threatened conclusion. The 
case is clear, and diagnosis unequivocal. But we often meet 
women who are worshiping at the shrine of the goddess Isis. 
So extremely desirous are they to present their husbands with 
heirs, that every possible sign of pregnancy has been magnified 
as a support to fond hopes, and the symptoms now presented, 
though really those of a menstrual return, are construed to be 
signs of abortion. There are women of opposite desires and 
tendencies who will minimize every true symptom, and thus 
mislead themselves, and those who are summoned to their aid. 
Then there are those unfortunate females, many of them girls 
scarcely out of their teens, who, having fallen a prey to the wiles 
of designing men, use every endeavor to conceal the evidences 
of guilt. Among the number are sometimes found those to 
whom we would scarcely dare impute wrong doing, and who 
thereby disarm suspicion. The only safe course for the physi- 
cian to pursue is to insist upon an examination per vaginam in 
all cases where, from the symptoms, there appears to be the least 
possibility of threatened, or partially completed, abortion. The 
diagnosis is based upon the presence of pain, hemorrhage, dila- 

'■' Boston Med. and Surg. Jour., April, 1871. 



PROGNOSIS. 193 

tation of the cervix, and descent of the ovum. If the os has 
become patulous, the ovum may be felt, when the demonstra- 
tion becomes complete. In all cases of pregnancy, the occur- 
rence of hemorrhage, even unaccompanied by other symptoms, 
ought to be accepted as a probable evidence of threatened 
abortion, and every precaution accordingly exercised. 

It is impossible to make out with certainty, from mere sub- 
jective symptoms, the existence of pathological changes in the 
ovum and deciduse which prepare the way for abortion. Death 
of the embryo may be inferred from the signs given in another 
chapter; but positive knowledge can be obtained only at a later 
period. 

Whenever the discharged substances have been preserved, the 
physician should carefully examine them with a view to discov- 
ering every possible trace of the ovum. The clots may be bro- 
ken up in cold water, and solid substances wholly freed from ex- 
traneous matters. The ovum, when unruptured, is generally 
found surrounded by layers of coagulated blood, and might 
easily be overlooked. If the discharged substances have not 
been preserved, and the os uteri will not admit the point of the 
finger, it may be impossible to determine at once whether com- 
plete evacuation has been effected or not. Forcible measures 
are not justifiable for mere diagnosis. The occurrence of fur- 
ther pain and hemorrhage would constitute strong evidence of 
retention, and dilation of the os may be necessary as a prelimi- 
nary to extraction of the remaining substances. 

Prognosis., — " The prognosis takes cognizance, of course, of 
the results to the mother only. In the first place, it may be laid 
down in the way of broad, general statement, that all cases of 
spontaneous abortion (i. e., excluding criminal cases), not com- 
plicated with other morbid conditions, are, under suitable medi- 
cal guidance, devoid of danger. But, in the second place, it 
must be borne in mind that the statement is only true with the 
reservations that limit it, for in point of fact, the actual number 
of deaths from abortion is by no means inconsiderable. Thus, 
the deaths from this cause reported to the Bureau of Yital Sta- 
tistics of New York city, between the years 1867 and 1875, in- 
clusive, were one hundred and ninety-seven, a number which 
falls short in all probability of the truth, by reason of the many 
circumstances which precisely in this condition tempt to con- 



194 ABOKTION. 

cealraent. The total number of deaths during the same period 
from metria was, according to the reports rendered, 1,947. Hegar 
reckons one abortion to every eight or ten full-time deliveries. 
If this proportion be correct, it would seem to show that the 
mortality from abortion is hardly second to that from puerperal 
fever itself. 

" Death, as a consequence of criminal abortion, is especially fre- 
quent. M. Tardieu found that in one hundred and sixteen such 
cases of which hewas able to ascertain the termination, sixty women 
died. But even in spontaneous cases death may take place from 
hemorrhage, from septicaemia, or from peritonitis. In many 
cases the fatal termination is fairly attributable to the ignorance, 
the imprudence, or the willfulness of the patient. How far the 
dangers of abortion may be neutralized by proper medical as- 
sistance is best shown by the statistics of large hospitals. Thus, 
I gather from the reports issued by Dr. Johnston, during his 
seven years mastership of the Eotunda Hospital, in Dublin, that 
in two hundred and thirty-four cases of abortion treated in that 
institution, there was but one death, and that not from puerpe- 
ral trouble, but from mitral disease of the heart. Bellevue Hos- 
pital is the receptacle ^annually of a tolerably large number of 
women suffering from incomplete abortions, many of whom enter 
the hospital in a very unpromising condition from either exces- 
sive hemorrhage or septic decomposition of the retained por- 
tions of the ovum. Yet, of the many cases whose histories I 
find in the record books of the hospital, all have ended in re- 
covery." — Lusk. 

Treatment. — The treatment of abortion is: 1. Preventive, 
2. Promotive, and 3. Remedial. 

Preventive Treatment. — This involves (a) general and spec- 
ial prophylaxis, and (b) the arrest of threatened abortion. 

The pregnant woman, and especially she who has already suf- 
fered one miscarriage, or more, should attend most scrupulously 
to the observance of general sanitary rules. Over-indulgence 
and over-exertion are particularly to be avoided. No amount of 
exercise should be laid out for pregnant women indiscrimi- 
nately, for what may justly be regarded as moderate exercise for 
one, will far exceed the endurance of another. 

Women who have had repeated abortions, at or near a certain 
period in pregnancy, must be guarded with the greatest care. 



TREATMENT. 195 

It is sometimes advisable to put them in close quarantine, and 
even in bed, for a time, though no threatening symptoms have 
arisen. When the period at which an interruption of pregnancy 
generally occurs in an individual case has passed, the woman's 
restraints may be gradually lessened, until they have reached a 
minimum. So strong a propensity is sometimes generated by 
recurrent abortion, that the unexpected arrival of a friend, a 
visit to the table, or even a strong odor, may be sufficient to 
bring on the accident. 

The treatment of certain constitutional dyscrasiae, as well as 
chronic and acute disease in general, of which the woman may 
be the subject, is also included in prophylaxis, but methods of 
treatment and the selection of remedies are modified so little by 
the patient's pregnancy as not to demand special consideration 
here. The same may be said also of accidents, from which preg- 
nant women are not exempt. 

Since strong emotions, which in a non-pregnant state could 
do no harm, are capable of producing, during gestation, most 
serious consequences, they ought to receive attention. After 
violent anger, colocynth and chamomilla are of considerable ser- 
vice. When anger or vexation is associated with fright, aconite 
may be employed. It is also of service when, after fright, a state 
of apprehension and dread remains. Opium also has the repu- 
tation of effecting favorable results after fright. To avert the 
evil effects of grief we can probably do no better than to admin- 
ister ignatia or phosphoric acid. 

After a bruise a few doses of arnica ought not to be omitted. 

A strain generally excites uterine action by rupture to a cer- 
tain extent of the utero-placental relations; still good may occa- 
sionally be done by the timely administration of rhus toxicoden- 
dron. 

After marked symptoms of threatened abortion have appeared, 
the first point to be decided is whether the abortion ought to be, 
or can be, prevented. In general, the physician should firmly 
and conscientiously be in no way accessory to abortion, and only 
when he is convinced that the foetus is dead, or that discharge is 
inevitable, should he assume the responsibility of promoting the 
act already begun, or passively permit the consummation of 
it. This principle of action, closely followed, gives considerable 



196 ABORTION 

scope for the employment of preventive measures, when once the 
expulsive forces of the uterus have been aroused. 

Little time should be lost in getting the woman into a bed, 
which has cool, pleasant, and quiet surroundings. Her clothing 
must be removed, and loose garments substituted, at the earliest 
practicable moment. If the hemorrhage is profuse, the hips 
may be raised by something laid directly under them, or, better 
still, by the foot of the bed set upon blocks. In a certain per- 
centage of cases, perfect repose of body and mind, is 
all that is required; but when uterine action has been fairly 
excited, when the hemorrhage is profuse, or has existed for some 
time, further means of prevention will be required. The simili- 
mum of the case should be sought, and, if found, it may quiet 
the pains and arrest the flow in a magical way. 

There are a few remedies which are of frequent service at such 
a time, but whenever any remedy is called for by clear indica- 
tions, whether its special sphere of action is the generative, or 
not, it should be administered. 

Sabina is a prominent remedy, especially in threatened abor- 
tions about the third month of pregnancy. The hemorrhage is 
rather profuse, of a bright red color, and is accompanied with 
clots. Its action is more prompt and efficient in nervous hyster- 
ical women, but need not be limited to such. In the absence of 
clear indications for some other remedy, we do well to employ 
this. 

Secale cornuium is best suited to thin cachectic women. The 
blood is dark and uncoagulated. Pulsatilla should be adminis- 
tered in those cases where the flow ceases for a time, and then 
returns with greater vigor. It is best adapted to mild, tearful 
women. Caidophyllum is the remedy when the pains are spas- 
modic and pressive, worse in the back and loins, with evidence 
of feeble uterine contractions. Slight flow; vascular excitement; 
tremulous weakness. 

Gratifying results are sometimes obtained from the above rem- 
edies. To them we may add aconite, with its great fear of death, 
and of stir, or bustle; nux moschata, with its hysterical symp- 
toms and syncope ; and belladonna, with its bearing-down sensa- 
tion, and bright red blood, which feels hot to the parts over 
which it flows. 

In old-school practice, opium constitutes the great reliance for 



TREATMENT. 197 

the prevention of abortion in these instances where threatening 
symptoms have arisen, and there is no sort of doubt that it 
proves efficacious in many cases which would otherwise culmi- 
nate in expulsion. This fact should not be ignored, and, when 
other remedies do not produce prompt results, we need not hesi- 
tate to avail ourselves of the benefits derivable from a discrimina- 
tive use of the drug. The most efficacious mode and form of 
administration is the hypodermic injection of morphia. One- 
eighth to one-fourth grain will generally be an adequate dose. 
Begin with the minimum quantity, and repeat it, if necessary. 

In every case of threatened abortion occurring during the first 
three months of pregnancy, a careful examination ought to be 
made to ascertain the situation and position of the uterus. In 
some instances the symptoms depend upon retroflexion and retro- 
version, and they often quickly disappear when, upon placing 
the woman in the knee-chest position, and carefully using the 
fingers, or the elevator, the organ is returned to its normal posi- 
tion. 

It is evident that preventive treatment is not suitable to all 
cases. The consummation of the process is sometimes clearly 
inevitable from its very incipiency. For a considerable time 
there may have existed evidence of the subsidence of the normal 
developmental activities, resulting, doubtless, from foetal death. 
The usual symptoms of pregnancy have become less pronounced; 
there is a sense of weight and bearing in the pelvis, associated 
with a feeling of coldness in the abdomen, and sometimes a viti- 
ated vaginal discharge. The woman is ill in body, and distressed 
in mind. In such a case interruption of pregnancy should never 
be prevented. On the contrary, cases which at first appear to 
be preventable, may, by a persistence and an aggravation of 
symptoms, ultimately pass the bounds, and become unqualifiedly 
unavoidable. 

The signs of inevitable abortion are profuse hemorrhage, dis- 
charge of clots from the uterus, dilatation of the os externum, 
descent of the ovum, and rupture of the membranes. While we 
cannot concur in the opinion expressed by some authors that 
rupture of the membranes is not proof positive that abortion is 
inevitable, we would caution against too hasty a presumption of 
•its inevitability. Scanzoni* has reported a remarkable case in 

*" Lehbuch der GeburtsMlfe," Wien, 1867, p. 83. 



198 ABORTION. 

which a woman was seized with profuse hemorrhage from the 
uterus in the third month of gestation; numerous clots were dis- 
charged, and all hopes of preventing the threatened occurrence 
were dissipated; ergot was given in full doses, the vagina was 
packed for many hours, and a sound was passed into the uterine 
cavity. After the hemorrhage had continued actively and pas- 
sively for three weeks, a weak solution of perchloride of iron was 
injected; but, despite all interference, the pregnancy continued, 
and quickening was experienced six weeks later. 

Promotive Treatment. — When the case has advanced beyond 
the limit where preventive treatment is available, the existing 
conditions do not always favor the immediate adoption of efforts 
at uterine evacuation. The os uteri, or, indeed, the entire cer- 
vical canal may be so small that it will not admit a single finger, 
while the uterus is pouring out blood in alarming quantities. In 
such an emergency something must be done at once to protect 
the woman from the serious consequences of excessive deple- 
tion, while the cervix is given additional time for expansion. In 
some cases dilatation may be speedily effected with the finger, if 
the uterus is kept within reach by firm pressure upon its fundus. 
If the ovum, in early abortion, is found intact within the os 
uteri, no interference whatever should be practiced unless the 
flow assumes serious phases, for fear of rupturing it, and thereby 
complicating the delivery. 

The Tampon. — Articles of various kinds have been recom- 
mended for vaginal tampons, but it matters less what is used 
than how it is used. A poorly applied tampon is worse than 
none. If strips of silk, linen or muslin are employed, they 
should be smeared with cosmoline or lard, and pushed, one at a 
time, into the vagina, until the latter has been well packed. 
Charpie, or raw cotton, when properly used, makes a most effi- 
cient tampon. The chief essential in any case, is to thoroughly 
distend the upper portion of the vagina, and tightly pack the 
space about the cervix, but to do this requires the greatest care., 
A number of pieces of size suitable for introduction may be pre- 
pared by being dipped into a disinfecting solution, and the fluid 
then expressed. About each of these a string should be tied, 
by means of which extraction can be effected without pain. One 
of these at a time can be deposited, at first near the cervix, until 



TREATMENT. 199 

the vagina is well filled. The early part of this operation can 
best be done through a speculum. A roller bandage makes a 
good tampon, and admits of easy removal. The same is true of 
lamp-wicking, recommended by Dr. F. P. Foster.* 

In the introduction of a tampon much difficulty will be ex- 
perienced, and great suffering inflicted, unless the precaution is 
observed to separate the labia and retract the perineum with the 
fingers of one hand, or by means of a speculum, while the arti- 
cle employed is being passed by the fingers of the other hand. 
This subject is considered at greater length in another chapter, 
to which the reader is referred. 

Before introducing a tampon, the vagina should be thoroughly 
washed with a disinfecting solution. No tampon ought to be 
allowed to remain in situ for more than twelve consecutive hours. 
It can be renewed at the end of that time if necessary. The 
precaution should be observed to cleanse the vagina with an 
antiseptic solution after removal of the tampon. The ovum 
often passes into the vagina, when the tampon is taken away. 
If it does not, dilatation may be sufficiently advanced to enable 
the operator to easily remove the foetus and envelopes in an un- 
broken state. 

As soon as dilatation has advanced far enough to admit of 
interference with a reasonable prospect of immediate success, it 
should be undertaken. In default of this condition, another 
vaginal plug, if required, may be introduced for twelve hours, 
but the use of this expedient for a period much in excess of 
twenty-four hours, is not to be recommended. The vagina be- 
comes irritated, more or less blood decomposition ensues, and 
septic matters are generated. 

Fig. 94. 




The ovum forceps. 

Instead of resorting to it at all, some prefer to use sponge 
tents. In case the tampon has been employed for the above 

* " N. Y. Med. Jour.," June, 1880. 



200 ABORTION. 

limited period, and the conditions which originally called for it 
have not disappeared, resort may be had to the sponge tent. 
This cannot be safely left so long as the vaginal tampon, and if 
its position is maintained, its usefulness will in a measure be 
lost in the space of a few hours. Its removal should be followed 
by the vaginal douche. 

Emptying the Uterus. — The secundines, as well as the ovum, 
require removal, and this is not always accomplished with the 
utmost facility. The ovum or placenta forceps have been recom- 
mended, and can sometimes be successfully used, but cannot 
be regarded as safe except in those cases where the part retain- 
ed protrudes from the os uteri. As will be seen in a succeeding 
paragraph, the fingers afford the safest and best means of ex- 
traction. 

In miscarriage the foetus is extremely apt to present by the 
feet, and the utmost care and discretion must be exercised to 
avoid severing its head and trunk. This is not an uncommon 
accident, though by no means an insignificant one, as a retained 
head is not always easily extracted. In removing the foetus, as 
likewise in getting away the placenta, the operator ought to 
work about the mass, loosening first one side and then the other, 
so that it may not be torn. 

In those rare cases wherein the membranes are expelled and 
the foetus retained, the latter should be extracted without un- 
necessary delay. A foetus left behind would give rise to the 
same dangers as a retained placenta, viz. : hemorrhage, and sep- 
tic poisoning, and the rules of practice regarding unexpelled 
secundines, would apply with equal force to unexpelled foetus. 
In the latter case the operation would be attended with fewer 
difficulties than in the former. 

It may occasionally happen that the symptoms of abortion 
culminate in the expulsion of one foetus *and its membranes, 
while yet another child, with intact membranes, remains' in 
utero. In such cases the physician should assume the expectant 
attitude, and patiently await developments. If there are no 
discernible signs of foetal death, and no further abortive efforts, 
there surely is no excuse for interference. But should symp- 
toms of miscarriage continue, or - again become manifest, or 
should foetal death or disruption of the membranes be discov- 



WHEN AND HOW TO REMOVE THE SECUNDINES. 201 

ered, delay ought to be brief, for the woman's interests are best 
subserved by speedy delivery. 

In twin pregnancy, the membranes of the first child may be 
broken before foetal expulsion, and remain behind. In such a 
case we should discreetly await the natural efforts, indulging the 
hope that the placenta will be extruded without serious disturb- 
ance of the uterine relations of the second child. Nature failing 
to accomplish this, and no untoward symptoms arising, the case 
meanwhile being kept under strict surveillance may be permitted 
to go undisturbed for a day or two, but longer delay would be 
unwise. It is evident that the existence of twin pregnancy is 
rarely recognized until interference has gone so far as to insure 
complete evacuation of the uterus. 

When once the embryo or foetus is expelled, the case has not 
always reached its climax of difficulty and danger. Indeed, in 
many instances serious difficulty is now first met. Expulsion of 
the ovum, entire, is not an infrequent occurrence in early abor- 
tion. In other cases the embryo is first extruded, to be followed 
without much delay by the secundines. In later pregnancy this 
sometimes occurs, but in the main, the phenomena differ in some 
important respects. The abortive process goes on in a regular 
way until foetal expulsion has been accomplished, when the ute- 
rine efforts cease, and the placenta is retained for an indefinite 
period. Nor is such retention generally for a few moments only, 
as in labor at full term, but it is prolonged and persistent. 

What gives to such a condition a serious aspect is, that there 
grow out of it certain dangers, viz: hemorrhage and septicaemia. 
After labor at full term, the placenta, on account of certain de- 
generative changes, is more easily separable, and may be either 
expressed or extracted. When retained after abortion, the ute- 
rus is too small to admit of successful expulsion of the placenta 
by pressure, the umbilical cord is too frail to bear traction, and 
the vulva, cervix, and uterine cavity, are not sufficiently expanded 
to admit the hand. These are the conditions which render re- 
tention of the placenta after abortion a matter of so great mo- 
ment to both physician and patient. 

When and How to Remove the Secundines.— When the pla- 
centa is retained it sometimes becomes a point of great nicety 
to decide when to operate for its removal, and unless one has 



202 



ABORTION. 




adopted for his guidance rules of practice by which to regulate 
Fig. 95. Fig. 96. his conduct, he will be likely to stumble and 
vacillate in a very embarrassing manner. The 
profession are not in perfect accord with regard 
to the treatment of these cases, and the con- 
sensus of opinion is not easily collected. Many 
advise against early interference, preferring to 
wait hours, or even days, for natural expulsion. 
Others insist upon the advisability of immediate 
attempts to remove the retained secundines, even 
though the operation prove to be difficult. 

The placenta proper is not formed until the 
third month of pregnancy, but the proper em- 
bryonic envelopes of an earlier date constitute 
a mass several times larger than the embryo it- 
self, and require treatment varying but little 
from that given the placenta proper. We find, 
however, that the uterine cavity and cervical 
canal are so small at an early period in preg- 
nancy, that the finger is not always available, 
in which case interference should not be pushed 
to extremes, unless hemorrhage becomes trouble- 
some, or there is intimation of septic influ- 
ences; and then, the finger failing, the curette 
may be employed, but with the utmost care. 
The mass left in utero being small, will not of- 
ten create serious disturbance, but will harm- 
lessly disintegrate and escape in the discharges. 
In abortions of the third and fourth months, 
the treatment should be slightly at variance 
with this. The placenta is now formed, and 
must be removed; but when? and how? Im- 
mediately after expulsion or extraction of the 
foetus the cervical canal ought to be examined, 
and if expansion is great enough to admit the 
finger, the placenta should at once be removed. 
There is no excuse for delay. With one hand 
on the hypogastrium the uterus can be pushed 
down into the pelvic cavity, and its contents 
Sinit e i^trl-'uter d ine tllus brought within reach, when, by gentle 

curettes. 



WHEN AND HOW TO REMOVE THE SECUNDINES. 203 

manipulation, the entire mass can generally be removed. If 
the cervical canal will admit the finger, nearly, or quite, to the 
internal os, gentle endeavor will soon overcome resistance. If 
neither dilatation nor moderate dilatability exist, the operation 
should be delayed for a time; but the placenta ought not to be 
permitted to remain longer than twenty-four hours. 

The chief exceptions to the foregoing rules arise in connec- 
tion with those cases wherein the woman has either been greatly 
reduced by hemorrhage, which has temporarily ceased, or is in 
a state of extreme nervous erethism. Both these conditions 
would contra-indicate interference. In the former case the 
patient must be kept under strict observation, while time is given 
the natural energies to recuperate. China may meanwhile be 
administered. Should hemorrhage set in, the placenta should 
at once be removed. In the latter case, efforts ought to be made 
to modify the nervous excitability, before resorting to interfer- 
ence. The most effective remedies are actcea racemosa, ignatia, 
hyoscyamus, asarum, camphor (2 x), coffea, stramonium, kali 
brom., or even chloral hydrate. Delay in excess of twenty-four 
hours ought not, as a rule, to be permitted. Bring the patient 
carefully under the influence of an anaesthetic, and proceed with 
the necessary operative measures. In truth, it often happens 
that when the placenta is retained, the woman, especially if of a 
nervous organization, is thrown into a condition of extreme ner- 
vous excitability, which cannot be wholly relieved while the 
placenta remains. 

Traction on the cord should not be made in such cases, be- 
cause it will not be of the least service, and will almost certainly 
result in tearing the cord away, thereby removing what is fre- 
quently a valuable guide to the finger in further attempts to re- 
move the placenta. 

In abortions at the fifth month, operative procedures should 
not be delayed longer than ten or twelve hours. In abortions 
at the sixth month, we need not wait longer than two or three 
hours. 

Expulsion of the placenta may sometimes be brought about 
by administration of pulsatilla, china or sabina. 

In any case when the os uteri is too small to at once admit 
the finger, gentle, yet persistent endeavor, will usually be effect- 
ual. If, owing to spasm of the circular fibres of the os uteri, or 



2CM: 



ABORTION. 



extreme sensitiveness of the woman, extraction of the placenta 
cannot be effected, an anaesthetic should be administered. 
Other means will rarely be required. In abortions at the fifth 
and sixth months, the uterus is so large that three or four fin- 
gers may have to be introduced to bring the operation to a suc- 
cessful conclusion. 

When the placenta has been removed in fragments, or when, 
in the absence of positive knowledge of what has been extruded, 
the finger is introduced for exploratory purposes, the convoluted 
endometrium may easily lead one to suppose that something 
still remains. It is only by most painstaking examination that 
the truth can be elicited. 

The placenta is sometimes so closely adherent to the uterus 
that removal of the entire mass, even in fragments, is impossi- 
ble, and there remains the danger of hemorrhage and septicaemia. 
If profuse hemorrhage should at any time occur, water at a 
temperature of say 110° or 115° Fahrenheit, injected directly 
into the uterine cavity by means of a syringe throwing a gentle 
stream, free from air, is a most excellent means of overcoming 
it. There is little or no danger connected with this use of - hot 
water, provided the os is large enough to permit free escape of 
the fluid injected. 

Similar injections have 
been employed with excellent 
results for hemorrhage con- 
sequent on total retention of 
the secundines, substituting 
the tedious and painful use of 
the finger, or instruments. In 
a goodly proportion of cases 
the uterus is stimulated to 
immediate contraction, result- 
ing in placental expulsion and 
arrest of the hemorrhage. 

When by the means des- 
cribed we are unable to de- 
press the uterus far enough 

Vertical section of pelvis, showing uterus to admit of digital extraction 
drawn down with the volsella. 

or the placenta, we may cause 

the organ to descend by means of the volsella. Abortions 



Fig. 97. 




WHEN AND HOW TO REMOVE THE SECUNDINES. 



205 



are much more frequent in multigravid, than in primigrayid, 
women, and it is chiefly in the latter class, and in those whose 
abdominal walls present an unusual thickness of adipose 
tissue, that the fingers, aided by abdominal pressure, will fail. 
But in these exceptional cases we may seize the cervix with the 
Yolsella, one with a slight curve being prefered. One blade 
should be passed within the os for about half an inch, and the 
other rest upon the outer aspect of the cervix at a corresponding 
level. With a hold thus obtained, the uterus may be drawn 
down without injury to either it, or its ligaments, and held by 
one hand, while the fingers of the other are passed into the cav- 
ity of the organ, to explore and evacuate it. 

Precedence and preference are by some given the placenta for- 
ceps, and the small blunt hook, as a means of extracting the pla- 
centa; but the vast majority of operators prefer the fingers. Still 
there are cases in which, from our inability to bring the uterine 
cavity within reach, or from the brevity of the physician's fingers, 
the instruments mentioned are capable of rendering efficient aid. 
Separation of adherent portions of placenta should never be 
entrusted to instrumental means, unless the sense-guided 
fingers utterly fail. The placenta forceps are constructed with 

Fig. 98. 




Loomis' Placenta Forceps. 
Fig. 99. 



,$8mmss&&s5&s^^ 



Schnetter's Placenta Forceps, 
slim shanks, and sometimes spoon-like blades, the inner surface 
of the latter being roughened, so as to afford a firm hold, other 
patterns are like those in figures 98 and 99. In order to pass 
the instrument, the fingers of one hand should be laid in the 



206 



ABORTION. 



Fig. 100. 



(n 



vagina, with their points at the os uteri, and along their palmar 
surface the instrument should be directed into the uterus. With 
the handles well back against the perineum, the blades are sepa- 
rated and an effort made to inclose the placenta. This is an 
operation which requires some skill, and, like many other obstet- 
ric procedures, is more easily described than performed. Ex- 
treme care should be exercised to avoid traumatism. When the 
placenta is taken hold of, forcible traction ought not to be made, 
as its fragile structures are easily broken. By gentle rotation of 
the instrument, first one way and then the other, associated with 
moderate traction, the retained part may often be delivered 
entire. 

Small blunt hooks for similar use have been 
constructed, and are more practical instruments 
than the placenta forceps. Such an aid may be im- 
provised as follows : Take a piece of pretty stiff 
iron or copper wire, and bend it in the middle until 
the two ends are brought together. The looped 
extremity thus formed should be turned over about 
half an inch, in the shape of a fenestrated hook. 
This may be introduced similarly to the placenta 
forceps, and delivery performed by a series of 
traction efforts upon different parts of the retained 
mass. An instrument consisting of a small hook 
and lever, like that shown in figure 100, is some- 
times serviceable in these cases. 

In nearly all instances bleeding ceases as soon as 
the uterus is fully evacuated, and when it persists, 
especially if it comes in little gushes, at intervals, 
we may be pretty sure that a fragment of the ovum, 
or a hard coagulum, remains behind. The finger 
should be again passed, if the cervix will admit it, 
and every part of the uterine wall examined. If 
anything is found it must be removed. Should 
bleeding still continue, as it will rarely do, the cavity 
may be gently scraped with the curette. 

When this is faithfully done, hemorrhage is al- 
most certain to cease; but, owing to constitutional 
Small hook peculiarities, such treatment may now and then be 
and lever. inadequate, and special medication be required. 




NEGLECTED CASES. 207 

In the absence of well-defined indications for some other 
remedy, china is to be given Pulsatilla, secale, caulophyllum, 
and phosphorus are often of service. The favorable outcome 
of miscarriage, as of labor at full term, depends almost wholly 
on a proper manual and instrumental conduct of the case, and 
does not often require extensive therapeutical measures. To 
depend upon the latter in the emergencies which abortion pre- 
sents, to the neglect of other and better means, is, like a similar 
proceeding in post-partum hemorrhage, the very height of folly. 

Anti-Septic Precautions. — The various measures which have 
been recommended for the conduct of abortion in different stages 
of the process, should always be employed under antiseptic pre- 
cautions. Neither the fingers, nor any instrument, ought to be 
introduced into the uterus, or even into the vagina, without 
first being thoroughly cleaned and disinfected. To do other- 
wise is to subject the woman to increased dangers, and do all 
concerned a grievous wrong. 

Neglected Cases. — The most threatening emergencies which 
the physician is called to meet, sometimes grow out of the neg- 
lect of women to avail themselves, in season, of professional care. 
It is assumed that the abortive act has been consummated, until, 
after the lapse of days or weeks, serious symptoms are mani- 
fested. A passive flow has existed for some time, when suddenly 
the blood gushes forth so profusely that the woman's life forces 
are speedily brought low. A physician is hastily called, and he 
finds his patient exsanguine and syncopal. The flow has tempo- 
rarily ceased. Reflecting upon her low state, and realizing that 
the last few drops are those which kill, his good sense tells him 
that the present is no time for interference. The voice of a wise 
monitor whispers: " To disturb those clots may be to kill," and 
he wisely heeds it. He revives his patient by judicious stimu- 
lation, and the administration of china, while a constant watch is 
kept to prevent an unobserved renewal of the flow. Should it 
occur, he will remove the secundines without delay; but in its 
absence, time for recuperation of the vital forces is given, and 
then the case is terminated without danger. 

In another instance the placenta, through neglect, is suffered 
to remain in utero. After a time certain ill-feelings are expe: i ■ 
enced: there is a chill, the pulse is accelerated, the temperature 



208 PATHOLOGY OF THE DECIDUA AND OVUM. 

rises; then follow headache, backache, fetid discharges, pros- 
tration, and all the signs of what has been called iritative fever. 
A physician is called in to explain the slow "getting up," and 
recognizes the alarming condition of his patient. He does not 
hesitate nor delay: — the uterus is at once emptied and washed 
out with a disinfecting solution. This treatment is generally 
followed by marked and immediate improvement; but sometimes 
the poisonous matters have been absorbed in so great quantities, 
and suitable treatment has been so long delayed, that the patient 
cannot be rallied. 



CHAPTEE IX. 

Pathology of the Decidua and Ovum. 

The physiological changes which take place in the uterine 
mucous membrane as the result of impregnation, sometimes pass 
the usual bounds and become pathological. It appears proba- 
ble that abortion not infrequently owes its origin to such a 
cause. 

Endometritis. — This may be either acute or chronic. The 
latter variety of the affection is divided into three distinct forms, 
viz: 1. Endometritis decidua chronica diffusa, 2. Endometri- 
tis decidua tuberosa et polyposa, and 3. Endometritis decidua 
catarrhalis. 

The causes of the first form probably depend, in a great meas- 
ure, on endometritis which antedates conception. Syphilitic 
infection, excessive physical exertion, and foetal death, with 
retention, are also set down as etiological factors. The anatom- 
ical changes which take place consist in thickening and harden- 
ing of the decidua, resulting from diffuse development of new 
connective tissue, and proliferation of decidual cells. The 
decidua vera and decidua reflexa may be separately or jointly 
involved in the processes, and changed in whole or in part. 
According to Duncan,* the hyper trophied decidua always pre- 

DUNCAN, " Researches in Obstetrics," p. 293. 



ENDOMETRITIS DECTDUA. 209 

sents evidence of fatty degeneration, unequally advanced in clif- 
erent parts. When the changes are wrought in the latter part 
of pregnancy, they pursue a notably chronic course, are limited 
in extent, or do not involve the placental decidua, and pregnancy 

Fig. 101. 




Hypertrophied Decidua laid open: ovum ax the fundus. 

does not invariably suffer interruption. Premature expulsion is 
caused in these cases by death of the ovum from imperfect 
nutrition, or by the exciting of reflex uterine action. The ovum, 
after death, generally retains its connection with the decidua for 
a length of time, and finally the diseased decidua and attached 
ovum are expelled. The decidua is a thick triangular fleshy 
mass, and has attached to some part of its inner surface, the 
blighted ovum. Expulsion is apt to be a slow process, owing to 
the adhesions which have formed between the decidua and the 
deeper uterine tissues. If these include the placental decidua, 
much difficulty will be experienced in natural separation of the 



210 PATHOLOGY OF THE DECIDUA. 

organ, and the case is liable to be complicated by profuse hem- 
orrhage. 

The causes of the second variety of chronic endometritis are 
obscure. Virchow regarded syphilis as one of them. Gusserow 
says that when conception closely succeeds delivery, the recently 
formed vascular uterine mucous membrane may take on abnor- 
mal proliferative processes. This variety of endometritis, and 
the pathological changes which result, are limited, with rare ex- 
ceptions, to the decidua vera, and prefer for their location the 
anterior and posterior walls of the cavity. " The uterine surface 
of the decidua is rough, and covered with coagulated blood, 
while the entire mucous membrane is exceedingly vascular. 
Upon that surface of the decidua which is directed toward the 
ovum, are situated large excrescences or elevations, the prevail- 
ing shape of which is polypoid. They may, however, appear in 
the form of nodules, of cones, or of boss-like projections, pro- 
vided with a broad, non-pedunculated base. Their height is 
from one-quarter to one-half inch, and their surface is smooth, 
very vascular, and devoid of uterine follicles. The latter, how- 
ever, are plainly visible on the mucous membrane intervening 
between the polypoid outgrowths, but they are compressed, and 
their orifices constricted or obliterated by the pressure of whit- 
ish, contracting bands of newly developed connective tissue. 
Similar fibrous bands surround the blood-vessels. On section, 
the larger prominences sometimes appear permeated with coag- 
ulated blood, and narrow, cord-like bands of hypertrophied 
decidual tissue occasionally form bridge-like connections be- 
tween neighboring polypi. The uterine follicles are, in some 
cases, filled with blood clots. The epithelium is often absent 
from the uterine surface of the decidua, except around the ori- 
fices of the follicular glands, and the deeper decidual tissues 
contain large numbers of lymphoid cells. The cells of the de- 
cidua reflexa frequently undergo fatty degeneration. The pla- 
cental villi may show hypertrophy of their club-shaped ends, or 
be the seat of myxomatous growths, in which case their cells are 
granular and cloudy. The foetus is generally dead and partially 
disintegrated. This form of endometritis decidua is, conse- 
quently, usually accompanied by abortion, which occurs pre- 
dominantly at an early stage of pregnancy." — Lusk. 

The third form of chronic endometritis attacks pluriparse 



ENDOMETRITIS DECIDUA. 211 

oftener than priroiparse, and runs a comparatively mild course. 
It has been termed hydrorrhea gravidarum, by which is 
meant a discharge of a clear watery fluid at intervals during 
pregnancy. Many theories have been formed regarding its eti- 
ology. Some have regarded the discharge as due to rupture of 
a cyst between the ovum and uterine walls. Baudelocque thought 
it proceeded from transudation of the liquor amnii through the 
membranes, while Burgess and Dubois believed it depends on 
rupture of the membranes at a point distant from the os uteri. 
Mattei has referred it to the existence of a sac between the chorion 
and amnion. A single discharge doubtless occasionally proceeds 
from the two last-mentioned causes, but repeated loss must be 
referred to other sources. Hagar's theory, that it is the result of 
abundant secretion from the glands of the uterine mucous mem- 
brane, which accumulates between the decidua and chorion, and 
escapes through the os uteri, is probably nearer the truth. The 
real pathological changes which take place are vascularity, hy- 
peremia, and hypertrophy of the interstitial connective tissue, 
and of the glandular elements of the decidua.* The inflamma- 
tion involves the decidua vera by preference, but may simulta- 
neously affect the decidua reflexa. f The fluid which results is 
thin, watery, muco-purulent, or sero-sanguinolent, resembling 
the liquor amnii both in color and odor. When no obstacle to 
its free escape is interposed, its discharge is continuous, but 
when it is confined, a considerable quantity may collect, until 
finally the resistance is overcome, and there is a sudden and co- 
pious discharge. It is often expelled at night while the patient 
is sleeping, brought about, very likely, by uterine contraction. 
In some cases even a pound, or more, of the fluid is thus lost. 
Hydrorrhcea gravidarum is observed at all periods of pregnancy, 
but it is most frequent in the latter months. It often occurs as 
early as the third month. 

Diagnosis involves differentiation between rupture of the 
membranes, the escape of fluid sometimes confined between the 
amnion and chorion, and escape of fluid emanating from the hy- 
pertrophied decidual glands. The chief point of differentiation 
between hydrorrhcea and escape of fluid from the space between 
the amnion and chorion, is that in the latter case there is but a 

* Spiegelberg; " Geburtshiilfe," p. 302. 
f Schroeder; " Geburtshiilfe," p. 394. 



212 PATHOLOGY OF THE CHORION. 

single discharge, while in the former there is either continual 
draining or repeated gushes. It is not always easy to distinguish 
between hydrorrhoea and escape of the liquor amnii. In the 
former we find that pains are absent, the os uteri unopened, and 
ballottemeni can be made out. If the membranes are ruptured, 
labor is quite certain to ensue, though cases of long retention 
after rupture have been recorded. A repetition of the discharge, 
and continuance of pregnancy, will materially aid in clearing up 
the diagnosis. Hydrorrhoea, though apt to cause alarm, pre- 
sents no serious phases. The pregnancy is rarely interrupted, 
and the woman feels rather relieved by the discharge. During 
the existence of this form of endometritis the general health of 
the woman should be as well maintained as possible, by strict 
observance of hygienic principles. Sexual intercourse, vaginal 
douches, and all possible sources of local irritation should be 
avoided. The remedies among which we will be most likely to 
find the similimum are arsenicum album, lachesis, nairum mu- 
riaticum, mercurius, calcarea carb, and sulphur. If uterine 
contractions supervene, the utmost quiet must be insisted upon, 
and caulophyllum, pulsatilla, or viburnum administered. 

Pathology of the Chorion. — The only affection of the cho- 
rion that has yet been described is that form' of degenerative 
change which results in the development of what is known as 
vesicular or hydatidiform mole, (cystic disease of the chorion, 
hydatiform degeneration of the chorion.) Before the time of 
Cruvelhier, the vesicles which characterize this morbid product 
were supposed to be real hydatids. Since his researches, others 
have confirmed the conclusions now held, and it is at present 
regarded as established, that the essential pathological process 
involved in the production of the vesicular mole consists in a 
proliferative degeneration of the chorionic villi. There is 
hypertrophy of the investing epithelium, of their connective 
tissue cells, and of their mucoid intercellular substance. As a 
result there are formed a large number of translucent vesicles, 
containing a clear limpid fluid, which closely resembles the 
liquor amnii, but contains more mucin. The vesicles vary in 
dimensions from those of a millet seed to those of a walnut, and 
form masses of considerable size. Small collections are more 
frequently met than those of large size. The larger cysts con- 
tain less mucin than the smaller. All the villi are not involved 



HYDATIDIFORM DEGENERATION. 



213 



in the process, and the normal tissue which intervenes between 
the vesicles, gives to the mass an appearance which somewhat 
resembles a bunch of grapes — the intervening normal tissues 
representing their connecting stems. Close examination widens 
the similarity, since the process of development is one of gem- 
mation, not from single stems, but mainly from vesicles already 
formed. When degenerative development begins in the first month 
of pregnancy, as indeed it usually does, before atrophy of the 
chorionic villi begins elsewhere than at the site of the forming 
placenta, the degeneration will involve its whole surface. Death 
and absorption of the embryo may ensue, leaving the amniotic 
cavity entirely free from solid matters. If the placenta has 
already been formed, degenerative changes will involve its struct- 
ure only, and if sufficiently extensive to destroy the foetus, the 
remains of the latter are found in the amniotic cavity, which 
sometimes contains an excess of liquor amnii. If only a few of 
the placental cotyledons are implicated, the foetus may continue 
its existence and growth, and reach a certain degree of perfec- 
Fig. 102. Fig. 103. 





Hydatidiform Mole. Hydatidiform Mole (placental origin). 

tion.* These changes generally take place within the decidua, 
*Spiegelberg, "Lehrbiich," p. 332. 



214 PATHOLOGY OF THE CHOKION. 

but that boundary is sometimes exceeded. Volkmann* reports 
a case in which the degenerative process invaded the uterine 
blood-sinuses, and, by pressure, led to so extensive an atrophy 
and absorption of the uterine walls, as to leave only a thin sep- 
tum between the mole and the peritoneal covering of the organ. 
" The cavity formed by this process of erosion in the uterine 
parenchyma was larger than the uterine cavity proper, and pre- 
sented intersecting trabecule resembling the columnae carneae of 
the cardiac ventricles." Such results, however, probably depend 
on a morbid condition of the uterine walls, proceeding from mal- 
nutrition. Similar cases, with fatal results, are reported by 
Schroederf. 

Sometimes the adhesion of the mass to the uterine walls is 
very firm, and may interfere with its expulsion. The nutrition 
of the altered chorion is carried on through its connection with 
the decidua, which also is often diseased and hypertrophied. 

Causes of Hydatidiform Degeneration. — The etiology of 
this disease has evoked considerable discussion. Some have 
supposed that the changes in the chorionic villi which character- 
ize it, are also preceded by embryonic death. In support of this 
view allusion has been made to the fact that, in nearly all cases* 
the embryo has been entirely absorbed, and also to the occasional 
occurrence of hydatidiform degeneration of the chorion of a dead 
foetus in twin pregnancy, while that of the living one remains 
healthy. That the exciting cause of the degenerative changes is 
often, if not usually, a morbid maternal condition, seems likely 
from its repetition in the same woman, by its co-existence with 
endometritis, or with extensive uterine fibroids, and by the exist- 
ence in most cases, according to Underbill, of a cancerous or 
syphilitic dyscrasia in the mother. If this be accepted, we must 
conclude that the degenerative changes generally precede and 
produce foetal death. The disclosure of the true pathology of 
hydatidiform degeneration has disposed of the question, form- 
erly mooted, of its occurrence independently of impregnation. J 
The theory of vesicular moles proceeding from a retained frag- 
ment of placenta is now regarded as having been clinically 

* Volkmann, " Virchow's Archiv.," Bd. xii, p. 528. 

t" Lehrbiich," p. 429. 

JMaddex, " Obstetrical Jour." Vol. viii, p. 42. 



HYDATIDIFOEM DEGENEKATION. 215 

refuted by the best clinical evidence, yet some very 
strong testimony in its favor stands upon the records.* 
Multipara are the subjects of vesicular moles much oftener 
than primiparae. This appears to proceed from advanced age, 
rather than from repeated pregnancies. The degenerative 
changes generally begin during the first month; while, according 
to Under hill, f the latter part of the third month is the extreme 
limit within which the disease can originate. 

Symptoms and Course. — Cystic disease of the ovum may 
exist for a time without developing any symptoms of sufficient 
prominence to draw attention. Later it is observed that the 
ordinary course of pregnancy has been changed in some impor- 
tant regards. Some of its most common symptoms may disap- 
pear, but such changes are by no means constant. The most 
prominent sign of the existence of perverted development con- 
sists in a failure of correspondence between the uterine enlarge- 
ment and the computed period of utero-gestation. Thus, at the 
third month, the uterus may be found as high as the umbilicus, 
or higher. On the other hand, if the cystic development began 

**' Taking this view of the etiology of this disease, it is obviousthat it is 
essentially connected with pregnancy, and that there is no valid ground for 
maintaining, as has sometimes been done, that it may occur independently of 
conception. It is just possible, however, that true entozoa may form in the 
substance of the uterus, which being expelled per vaginam, might be taken 
for the results of cystic disease, and thus give rise to groundless suspicions as 
to the patient's chastity. Hewitt has related one case in which true hydatids, 
originally formed in the liver, had extended to the peritoneum, and were about 
to burst through the vagina at the time of death. This occurred in an unmar- 
ried woman. One or two other examples of true hydatids forming m the sub- 
stance of the uterus are also recorded. A very interesting case is also related 
by Hewitt, in which undoubted acephalocysts were expelled from the uterus 
of a patient who ultimately recovered. A careful examination of the cyst and 
its contents would show their true nature, as the echinococci heads, with their 
eharacteiistic hooklets would be discoverable by the microscope." 

" It is also possible that unfounded suspicions might arise from the fact of a 
patient expelling a mass of hydatids long after impregnation. In the case of a 
widow, or woman living apart from her husband, serious mistakes might thus 
be made. This has been specially pointed out by McClintock, who says> 
' Hydatids may be retained in utero for many months or years, or a portion 
only may be expelled, and the residue may throw out a fresh crop of vesicles to 
be discharged on a future occasion.'" — Play f air, " System of Midwifery " Am. 
Ed., p. 222. 

t " Obstet. Gazette," Jan., 1879, p. 16, 



216 PATHOLOGY OF THE CHORION. 

early, the organ may be decidedly smaller than at a correspond- 
ing period in normal gestation. There is more general disturb- 
ance of the health than there ought to be, nausea and vomiting 
being apt to become excessive. Lumbar and sacral pains are 
prominent and distressing in proportion to the rapidity of the 
abnormal growth. About the third month, sometimes earlier, 
there begins a more or less profuse watery and sanguineous dis- 
charge, generally at intervals, which resembles currant juice. 
These losses doubtless depend on breaking of one or more of the 
cysts, and escape of the contents, brought about by painless uter- 
ine contractions. Though not usually excessive in quantity, 
they are sometimes so profuse and frequent as to reduce the 
woman's vital forces to a low, and even dangerous, condition. In 
the discharge are also found portions of cysts, and sometimes 
even masses of considerable size. 

Physical exploration discloses important signs. The uterus, 
as felt through the abdominal walls, sometimes presents irregu- 
larities, but which do not closely resemble foetal outlines, and it 
imparts to the examining hand a peculiar boggy, or doughy feel, 
and sometimes distinct fluctuation. On examination per vaginam, 
the lower uterine segment is found to present similar characters. 
Ballottement yields negative results, and fcetal movements are not 
felt, though they may be simulated by uterine contractions. The 
sounds of the fcetal heart are diminished in intensity, or are 
quite imperceptible. 

Expulsion of the degenerate mass usually takes place before 
the sixth month, but it may be delayed beyond the usual period 
of mature utero-gestation= As in the case of ordinary abortion, 
the hemorrhage ceases after the uterus has been completely evac- 
uated, but retained portions of the tumor may give rise to pro- 
tracted and profuse bleeding. 

Diagnosis. — In those cases where the cystic degeneration 
implicates but a part of the ovum, diagnosis cannot always be 
made with any certainty. The chief reliance as a basis for 
diagnosis, are the rapid increase of uterine development, and 
th* 3 peculiarities of the discharge, in which whole vesicles are 
at times found. Absence of the more important signs of normal 
pregnancy should be given due weight. 

Prognosis. — The character of the prognosis in cases of hy- 
datidif orm mole is governed largely by the frequency and violence 



HYDATIDIFOBM DEGENEKATION. 217 

of the accompanying hemorrhages. It is reassuring in the ma- 
jority of cases, as far as it regards the mother; but the life of 
the foetus is, of course, almost invariably sacrificed. 

Treatment. — The treatment differs but little from that pre- 
scribed for ordinary abortion, and consists, in the main, of 
measures calculated to control the hemorrhage, and promote 
expulsion of the degenerate product of conception. Non-inter- 
ference is generally advised until uterine action is excited, unless 
threatening symptoms are meanwhile developed. When con- 
tractions begin, the tampon should be used, if called for by 
profuse hemorrhage, and uterine action sustained by appropri- 
ate remedies. Under the expectant plan of treatment there is 
considerable danger to be apprehended from sudden and violent 
hemorrhage; therefore, unless arrangements of the best sort 
can be made for prompt professional attention, the question of 
immediate interference merits thoughtful consideration. Dila- 
tation may be begun with tents, and afterwards continued with 
the finger, or with the dilators of Molesworth, Barnes or Tar- 
nier. The remaining steps of the operation will be easy. With 
the fingers the mass is removed either whole, or in fragments, 
and the main difficulties of the case are soon overcome. Since 
there is sometimes firm adhesion of the cystic mass to the uterus, 
very energetic attempts at complete separation should be avoided. 

After delivery has been affected, the uterus ought to be washed 
out with aa antiseptic solution. If severe hemorrhage should 
ensue, hot water intra-uterine enemata may be used with benefit. 

Certain remedies have been said to promote the expulsion of 
moles, though their real efficiency for such a purpose is open to 
doubt. The most prominent of these are ferrum, 'kali carb., 
Pulsatilla, sabina, silicea, sulphur, mercurius, and natrum carb. 
Should one of these remedies, or any others, be indicated by 
any prominent characteristics, it should be administered. For 
the hemorrhage which in these cases occasionally follows deliv- 
ery, the same indications should be observed as in a similar 
occurrence after abortion, or even labor at full term. 

Pathology of the Placenta.— The pathology of the placenta 
is a subject of the greatest importance, and has in late years re- 
ceived considerable attention from obstetricians. 

Form. — The form of the placenta varies considerably. Its 



218 PATHOLOGY OF THE PLACENTA. 

usually round or oval shape is not always preserved, but it may 
be crescentic, or horse-shoe shaped, or have an irregular 
form, and be spread over a considerable surface, in consequence 
of an unusual number of the chorionic villi being concerned in its 
formation. That anomaly of form which deserves special men- 
tion, is the one in which a supplementary placenta exists. This is 
known as placenta succenturiata, the accessory developments 
being due to the persistence of isolated villous groups, which 
form vascular connections with the decidua vera. They are of 
consequence, inasmuch as they are liable to be left in utero, and 
give rise to persistent post-partum hemorrhage. Hohl says they 
always form at exactly the junction of the anterior and posterior 
uterine walls, and the portions of placenta on each side of the 
line become separated. 

Size. — Placentae vary also in size, the dimensions of the or- 
gan bearing a pretty constant relation to that of the child. Hy- 
pertrophied placentas occur chiefly in connection with hydram- 
nios, and consist of a genuine parenchymatous hyperplasia, the 
foetus being dead and shrivelled. In some cases the organ is 
remarkably small, which condition is referable to defective de- 
velopment, to premature involution, or to hyperplasia of its con- 
nective tissue, with subsequent contraction. It should be borne 
in mind, however, that the dimensions of the placenta are modi- 
fied by the state of its vessels. When the latter are empty, the 
organ may appear small, which when filled would be greatly in- 
creased in size. When true atrophy of the placenta exists, the 
vitality of the foetus is sure to be more or less impaired. Whit- 
taker* believes that atrophy of the organ depends either on a 
diseased state of the chorionic villi, or of the decidua in which 
they are implanted. The latter is supposed to be the more com- 
mon cause, and it consists in hyperplasia of the connective tis- 
sue of the decidua, which presses on the villi and vessels, and 
results in atrophy. 

Situation. — The most frequent situation of the placenta is at 
or near the fundus uteri, close to the orifice of the Fallopian 
tube, on one side of the uterus, or the other, but it is occasion- 
ally implanted elsewhere, as, for example, over the orifice of the 
Fallopian tube, over the internal os, as in placenta praevia, and 

* " Am. Jour. Obs.," vol. iii, p. 229. 



DEGENERATIONS AND NEW FORMATIONS. 



219 



at various points in the abdominal cavity in connection with ex- 
tra-uterine pregnancy. 

Degenerations and New Formations. — The most common 
form of degeneration is the fatty, which may be circumscribed, 
or diffused. It is normally present in a mature placenta, and is 
probably a change which facilitates the final separation of the 
organ. When it occurs early in pregnancy it is often regarded 
as a premature completion of the occurrence which always nor- 
mally takes place at a later period. Its cause is doubtless ref- 
erable to tissue changes which interfere with proper nutrition, 
proceeding, perhaps, in the first instance, from the woman's 
state of health. Syphilis, doubtless, in some cases, has an in- 

Fig. 104. 




Fatty Degeneration of the Placenta. 

fluence in its production. The placental tissues often present 
yellowish masses of different sizes, which consist largely of mo- 
lecular fat, penetrated by a fine network of fibrous tissue ; but 
the true fatty degeneration has a predilection for the chorionic 
villi. The latter, on careful examination, are found to be al- 



220 PATHOLOGY OF THE PLACENTA. 

tered in their contour, and loaded with fine granular fat-glo- 
bules. 

Other Morbid States of the placenta are: 1. Amorphous 
calcareous deposits, which are found on the uterine surface of 
the placenta, in the decidua serotina. The process sometimes 
extends to the foetal portion of the placenta. When the change 
begins in the latter part, it is generally limited to it, and affects 
the small blood-vessels of the villi, attacking first their terminal 
ramifications, and gradually implicating the trunks. 2. Depos- 
its of pigment, usually attributable to alterations in the haemoglo- 
bine of extravasations, found within the blood-sinuses or villi of 
normal placentae, are sometimes excessive. 3. (Edematous in- 
filtration of the placental tissue is sometimes observed. Accord- 
ing to Lange, it occurs only in connection with hydramnios. 4. 
Cysts are frequently found near the centre of its concave sur- 
face, and vary from a few lines to several inches in diameter. 
The amnion, covered with pavement epithelium, forms the cyst 
wall. A reddish, cloudy, thin fluid, makes up the contents. 
Ahlfeld* regards the cysts as liquified myxomatous formations. 
They may also develop from apoplectic foci. 5. Circumscribed 
tumors are occasionally found on the foetal side of the placenta, 
beneath the amnion. Spiegel berg tells us that these are fibro- 
matous or sarcomatous in character. Myxoma of the placenta, 
consisting in hyperplasia of the villi, and myxoma fibrosum pla- 
centae, characterized by the fibroid degeneration of the basement 
membrane in isolated villi, are the chief remaining varieties of 
placental neoplasms. 

Syphilis of the Placenta. — Placental syphilis, which only 
exists, according to Frankel, in connection with congenital or 
hereditary syphilis, involves the maternal portion of the pla- 
centa, when the mother is affected either before or soon after 
conception, and produces gummatous proliferation of the de- 
cidua, characterized by the development of large-celled connect- 
ive tissue, with occasional accumulations of younger cells. 

When the infection is conveyed by the father to the foetus 
alone, or to both mother and foetus, pathological changes occur 
as the result of a chronic inflammatory process, embracing pro- 
liferation of the cells and connective tissue in the villi, with sub- 

* " Arch, of Gynatk," vol. xl, p. 397. 



PLACENTITIS. 221 

sequent obliteration of the vessels, often complicated by the 
marked proliferation and hardening of their epithelial covering. 

"The affected villi become swollen, cloudy s and thickened, 
while their epithelium undergoes proliferation and cloudy swell- 
ing. The parenchyma of the villi is filled with lymph-cells, and 
the vessels are either compressed or obliterated. The blood- 
sinuses are gradually encroached upon by the villi, the foetus 
dies from lack of adequate nutrition, and the villi undergo fatty 
degeneration. Portions of the healthy placental tissue, which 
often intervenes between the diseased parts, may be the seat of 
extravasations. ' ' — Lusk. 

Placental Apoplexy and Inflammation. — Hemorrhage into 
the placenta sometimes takes place from congestion of the utero- 
placental vessels, proceeding from disturbances in the mother's 
vascular system.* The extravasation may be into the placental 
parenchema, into the serotina, or into the uterine sinuses. Ex- 
travasation is due mainly to morbid changes in the decidual 
vessels, often as the result of placentitis. The blood coagula 
undergo the ordinary retrogressive metamorphoses. Occasion- 
ally cystic, fatty, or calcareous degeneration takes place. The 
haematomata by pressure may interfere with proper nutrition of 
the foetus, and result in its death. 

Placentitis has been alluded to by some authors as a common 
disease, and various pathological changes have been attributed 
to it, such as hepatizations, purulent deposits, and adhesions to 
the uterine structures. Its very existence is now disputed by 
many, who contend that the morbid changes alluded to are due 
simply to retrogressive metamorphoses in coagula. " What has 
been taken for inflammation of the placenta," says Robin, " is 
nothing else than a condition of transformation of blood clots 
at various periods. What has been regarded as pus is only 
fibrin in the course of disorganization, and in those cases where 
true pus has been found, the pus did not come from the placenta, 
but from an inflammation of the tissue of the uterine vessels, 
and an accidental deposition in the tissue of the placenta." 
Other writers affirm its existence, and assign to it etiological 
relations with metritis and endometritis. According to their 
view the inflammation originates in the serotina, or in the ad- 
ventitia of the foetal arteries, generally producing granulation 

* " Nouv . Diet, de Me*d. et de Chirurg. Prat," vol. xxviii, "Placenta.' 1 p. 63- 



222 PATHOLOGY OF THE AMNION. 

tissue, which, from contraction, produces compression of the 
placental vessels, which, in turn, may result in their obliteration, 
and lead to fatty degeneration of the villi. Should the inflam- 
matory action be recent, the friability of the new granulation 
tissue may result in retention of parts of the placenta. 
Placentitis is sometimes accompanied with hemorrhages which 
prove fatal to the foetus. It rarely results in suppuration. 

Hydramnios — The chief pathological condition of the am- 
nion is that in which the liquor amnii exists in excessive quan- 
tity, known as hydramnios. This term should be restricted, 
however, to those cases in which the amount of fluid is so large 
that, by its pressure on the uterus, the abdominal or thoracic 
viscera, or the fcetus, morbid symptoms are developed. Dr. 
Kidd * limits the term to cases in which the amnion contains 
more than two quarts of the liquor. 

Etiology. — The precise cause is still a matter of doubt, but 
it probably depends upon a variety of morbid conditions, affect- 
ing either the mother or the foetus. It is more common in 
multipara than in primiparse, and in the vast majority of cases, 
the foetuses are females. It most commonly results from morbid 
states of the fcetus, and particularly from mechanical disturb- 
ances of the circulation, either in the placenta or cord. Kust- 
ner f relates a case in which the anomaly resulted from obstruc- 
tion of the umbilical vein, resulting from hepatic disease. The 
theory that the disease is of a purely local origin has been advo- 
cated by some, and it is certainly favored by the fact that when 
the condition is met in twin pregnancy, one ovum only is found 
to be affected. 

The fcetus is very often dead and shrivelled, and the placenta 
enlarged and cedematous. Still, we have no reason to infer that 
death of the fcetus is always consequent on the morbid condition 
in question. McClintock collected thirty-three cases, in nine of 
which the children were still-born, and of those born alive, ten 
died within a few hours. % 

Signs and Symptoms.— The excessive uterine and abdominal 
distension which results from hydramnios makes locomotion 

* " On the Diagnosis of Dropsy of the Amnion," Proceedings of the Ob- 
stel Society of Dublin, May 11, 1878. 
t " Arch. f. Gynack.," Bd. x, 1876. p. 134. 
% "Diseases of Women," p. 383. 



HYDRAMNIOS. 223 

difficult and painful. Its effects are chiefly mechanical, and are 
first noticeable at the fifth or sixth month. In advanced stages 
the distress which results from it is great: — the diaphragm is 
forced upwards, compressing the lungs and displacing the heart, 
thus producing dyspnoea, and cardiac palpitation; neuralgia 
and oedema of the labia and lower extremities result from com- 
pression of the pelvic nerves and vessels; direct compression 
of the stomach produces distress after even a small meal; while 
ascites may result from obstruction of the portal circulation. 

Inspection and palpation reveal great distention of the abdo- 
men, in advanced cases. The outline of the uterus can be easily 
felt, and there is unusual evidence of fluctuation, while the uter- 
ine and abdominal walls are extremely elastic and tense. The 
foetal movements are not so easily felt by either the woman or 
the examiner as in normal pregnancy, though there is greater 
freedom of action. The sounds of the foetal heart are scarcely 
audible. When the lower uterine segment is felt by the finger 
per vaginam, the resistance of the presenting part, is found to 
be less firm than usual, though the uterine walls are firm and 
tense. Premature expulsion of the foetus very often supervenes 
as the result of foetal death, of placental separation, or of over- 
distension of the uterus. The latter condition renders uterine 
action feeble, and hence the first stage of labor is greatly pro- 
longed. Should uterine inertia prevail in the third stage, hem- 
orrhage is liable to ensue. In general, however, upon rupture 
of the membranes and escape of the amniotic fluid, vigorous 
contractions ensue, and lead to precipitate expulsion. Involution 
is apt to be slow, and imperfect. 

Diagnosis. — In real hydramnios, diagnosis is not often at- 
tended with much difficulty. It is to be distinguished from 
twin pregnancy, from ascites, and from ovarian dropsy. In 
twin pregnancy, the foetuses can easily be felt, and the foetal 
heart-sounds are distinct, while the uterine walls, though tense, 
still present the evidences of distension from solid matter. As- 
cites will be recognized by the superficial situation of the fluid, 
by the depth of palpation required to feel the uterus, by the 
existence of dropsical effusions in other parts, and by the evi- 
dence elicited from palpation, that the fluid changes its bounda- 
ries to correspond to the various positions of the woman. Ova- 
rian dropsy may be distinguished from hydramnios by the 



224 PATHOLOGY OF THE AMNION. 

general history of the case, the point whence abdominal enlarge- 
ment proceeded, and the absence of the most common signs of 
pregnancy. Dr. Kidd calls attention to the fact that the position 
of the uterus, whether the organ is gravid or non-gravid, is 
usually low in the pelvic cavity, when an ovarian tumor exists, 
while in hydramnios it is so high as to be reached per vaginam 
with difficulty. 

Prognosis. — In four cases out of thirty-three collected by 
McClintock, the women died after labor, the result being attrib- 
uted to the debilitated state of the women who were subjects of 
the anomaly. Foetal mortality is very great. Nine of the thirty- 
three children were born dead, and ten died within a few hours. 

Effects of Amniotic Dropsy on Labor.— Even in those cases 
wherein the amniotic fluid is excessive in quantity, but still not 
sufficiently abundant to acquire the title of hydramnios, the 
effect on labor is to create feeble uterine action, and cause delay. 
This effect is more marked in the first stage, since at its close 
the membranes are usually broken. 

Treatment. — For the disease itself no remedy has yet been 
found. Should the mother's condition become distressing and 
perilous, the physician will feel called upon, in the interest of 
his patient, to puncture the membranes, and draw off the liquor 
amnii. Inasmuch, however, as this procedure is sure to be fol- 
lowed by foetal expulsion, it should be postponed as long as the 
woman's safety will permit. Playfair* suggests the possibility 
of puncturing the membranes with a fine aspirator needle, and 
modifying the distention by drawing off only a part of the fluid, 
thereby ' affording relief without bringing on premature labor. 
Disturbance of the mother's heart is one of the symptoms most 
urgently calling for interference. If, during labor, the excessive 
distention of the uterus retards dilatation of the os, the mem- 
branes should be punctured or ruptured, and the amniotic fluid 
permitted to escape. The unusual danger of post-partum hem- 
orrhage, which threatens in such cases, ought to be borne in 
mind, and the best precautions adopted. 

Deficiency of Amniotic Fluid.— When the liquor amnii is 
deficient in quantity, foetal movements are greatly restricted, 
and are liable to cause the mother much discomfort, from the 

*" System of Midwifery," Am. Ed., 1889, p. 229. 



KNOTS OF THE UMBILICAL CORD. 



225 



distinctness with which they are felt. From the same cause, 
pressure of the uterus upon the foetus may result in deformity. 
If the amnion is not separated from the foetus by a considera- 
ble amount of fluid, in the early part of pregnancy, abnormal 
amniotic folds, and adhesions between the amnion and the foetus, 
may take place. Foetal deformity, and intra-uterine amputa- 
tion, from mechanical compression by the so-called f ceto-amniot- 
ic bands thus formed, may be caused. 

Anomalies of Appearance of the Liquor Amnii. — The am- 
niotic liquor does not present constant characters. Instead of 
being limpid, and of an inoffensive odor, it may be thick, and 
emit a disagreeable smell. The cause of these variations is not 
well understood. 

Pathology of the Umbilical Cord. — The average length of 
the umbilical cord is about twenty-two inches, but extremes in 
both directions are exceedingly wide. Its minimum is about three 
inches, and its maximum about one hundred and eight inches. 
The cord, when unusually long, is liable to complicate preg- 
nancy by getting tightly drawn about the neck or limbs of the 
foetus. Intra-uterine amputation is probably occasionally per- 
formed by the pressure of the cord about an extremity, and 
foetal life is sometimes sacrificed in a similar manner. 

Fig. 106. 




Fig. 107. 




; ^3» 



Knots of the Umbilical Cord. 

Knots. — Knots on the umbilical cord are found once in two 
hundred cases. They result, in general, from the foetus, in its 
movements, passing through loops of the cord. Knots formed 
during parturition are loose, and easily untied. In any case, if 
there is an average amount of Wharton's gelatine in the cord, 



226 PATHOLOGY OF THE UMBILICAL COED. 

no harm will probably result from any knot which is likely to 
be tied. Knots formed during pregnancy, from their long con- 
tinuance, and the consequent absorption of Wharton's gelatine, 
occasionally produce fatal results. 

Torsion. — This is a more serious and frequent complication 
of pregnancy than the formation of knots. It consists in such 
an extreme rotation of the cord that the circulation is impeded. 
It occurs most frequently after the middle of pregnancy, and, as 
Spiegelberg assures us,* in the seventh month. Martin has 
shown f that the occurrence is not, as a rule, attributable, as has 
been supposed, to active movements of the foetus. He found 
that, in a good share of the cases in which foetal death has been 
rationally attributable to torsion, the pathological conditions ac- 
companying death from such a cause have been absent. He 
therefore arrived at the conclusion that torsion was in such cases 
a post-mortem occurrence, resulting from fcetal rotation pro- 
duced by maternal movements. These views have been supported 
by several other observers, among whom Schauta J is the most 
recent, who bases his conclusions upon three propositions, viz: 
1. Upon the large number of twists generally found, while any 
one of them is capable of producing foetal death. 2. Upon the 
improbability of extensive torsion in a healthy cord, inasmuch 
as compensatory reverse rotation would be caused by its elas- 
ticity. 3. Upon the fact that even twenty-five artificially-in- 
duced twists in a healthy cord caused rupture. He reports one 
case in which there were three hundred and eighty torsions of 
a single cord. Torsion occurs more frequently in long cords, 
and in multiparous women. Its seat is usually near the umbili- 
cus. Trombi are often found in the vessels, and cystic degener- 
ation in the cord. In the foetus are observed general oedema. 

Coiling of the Cord.— The umbilical cord is frequently found 
coiled about some part of the foetal body, most frequently the 
neck. This appears to be true in ten or fifteen per cent, of all 
cases. The number of such turns may reach six, or even seven, 
though more than one is an uncommon occurrence. When rap- 
idly developed, they may, in rare cases, lead to sudden interrup- 

*"Lehrbuch,"p. 350. 

f " Ztschr. f. Geburtsh. u. Gynaek," Bd. ii., Heft. 2, 1878, p. 346. 

t" Arch. f. Gynaek," Bd. xvii., Heft, 1, 1881, p. 20. 



HEBNIA OF THE COBD. 227 

tion of the umbilical circulation, and consequent death of the 
foetus. Should the coil be but moderately tense % at first, it 
gets tighter as the foetus develops, until compression may be- 
come great enough to interfere with the vascular supply of the 
part, and eventually lead to its entire death and separation. In 
other cases, the combined pressure of the cord, and of the slowly 
growing member, may interrupt the umbilical circulation, and 
produce foetal death. From a tense coil of the cord about the 
neck, the head of the foetus has sometimes been almost ampu- 
tated. "When the cord is coiled about the foetus at birth, partu- 
rition is occasionally impeded. Dr. George T. Elliot reports a 
case in which the head refused to enter the brim on account of 
a cord rendered short by two turns about the foetal neck. The 
forceps were applied, and labor completed with difficulty. From 
shortening of the cord thus produced, there may result anoma- 
lous positions, premature separation of the placenta, retarded 
labor, and even foetal death. 

Cysts. — Cysts of the cord are occasionally observed. They 
form within the amnion, and are produced either by liquefac- 

Fig. 108. 




Hernia of the Cord, 
tion of the mucoid tissue, or by accumulation of serum between 
the epithelial layers of the allantois. 
Hernia. — By hernia of the cord is meant the escape from the 



228 PATHOLOGY OF THE UMBILICAL COED. 

abdomen, at the umbilicus, into the cord, of some or all of the 
abdominal viscera. It arises either from arrested embryonic 
development, or the failure of the intestines, which were orig- 
inally situated outside the abdomen, to enter the cavity. Although 
hernia may occur in otherwise normally developed foetuses, it is 
usually accompanied by other deformities, such as stricture of 
the rectum, imperforate anus, or distortion of the lower limbs 
and of the genitals, resulting from traction of the displaced vis- 
cera on adjoining parts. The hernial sac is composed of the 
amnion and the peritoneum, and its contents are convolutions of 
the intestines, though other organs, as the liver, kidneys, spleen 
and stomach are sometimes included, leaving the abdomen nearly 
empty. 

Calcareous Deposits have been found in the cords of foetuses 
presenting evidences of syphilis. 

Stenosis of the Umbilical Yessels. — Atheroma, and subse- 
quent thrombosis, sometimes give rise to stenosis of the umbil- 
ical arteries. Chronic phlebitis, through development of new 
connective tissue, may produce stenosis of the umbilical vein, 
and occasionally, of the arteries. The latter process is usually 
referable to syphilis. 

Anomalies of Insertion. — Anomalies in the distribution of 
the vessels of the cord are of common occurrence. The cord 
may be inserted into the edge, instead of the center of the pla- 
centa, in which case the organ has received the designation of 
battledore placenta. It may separate before reaching the pla- 
centa, and its vessels traverse the membranes, in which case the 
anomaly is spoken of as insertio valamentosa. Traction on a 
cord so inserted would be manifestly dangerous to the integrity 
of its structures. 

Pathology of the Foetus. — Comparatively little is known of 
the diseases which attack the foetus in utero, though there is 
abundant evidence that they are numerous, and often fatal. 
Following are some of those which have been observed: 

Inflammations. — Various organs are attacked, the peritoneum 
being one of the structures most frequently involved. The 
pleura and lungs are also subject to inflammation. 

Blood Diseases Transmitted Through the Mother. — It has 
been found that various eruptive fevers are transmissible to the 
foetus through the mother. When a pregnant woman suffers 



FCETAL SYPHILIS. 229 

from confluent small-pox, abortion generally results, and the 
foetus has often presented evidences of having had the disease. 

Syphilis is a disease from which the foetus does not escape. 
Premature labor, and foetal death, are common results of the 
affection. The evidences are not always patent at birth, but a 
careful examination post-mortem, or attentive consideration of 
the subsequent symptoms in living children, discloses the true 
disturbing causes. 

Measles and Scarlatina are both known to affect the child in 
utero. 

Malaria and Lead Poisoning are also of frequent occurrence. 
M. Paul * has cited eighty-one cases in which the latter induced 
death of the child. In some instances the foetus was affected, 
while the mother escaped. 

Dropsies. — Hydrocephalus is the most common, but not the 
only form met. The fluid distends the ventricles, and as a re- 
sult there is expansion and thinning of the cranium, the bones 
of which are widely separated. Ascites and hydrothorax are 
occasionally observed. 

The foetus in utero is probably exempt from few diseases. 
The following, among others, have been reported: Pleurisy, 
scirrhus, tubercles, pneumonia, calcareous deposits, peritonitis, 
enteritis, worms, calculus, jaundice, rickets, caries, necrosis, con- 
vulsions, hemorrhages, etc. Tumors of various kinds, and in 
different situations, have been observed. Tarnier has reported 
meningocele larger than a child's head, and large cystic growths 
have been found attached to the nates, thorax, and other 
parts. 

Effects of Yiolence. — Accidents to the mother may involve 
the foetus, so as to leave permanent marks, without interrupting 
pregnancy. Extensive lacerations and contusions in various 
parts of the body have been observed. Intra-uterine fractures 
sometimes result from injuries, but there is no doubt that spon- 
taneous fractures also occur, and are nearly always multiple in 
the same foetus. Chaussier mentions a child born in 1803, after 
a rapid and easy labor, which had forty-three fractures, even the 
cranial bones being involved. He reports another case in which 
a child was born after an extremely short and easy labor, pre- 

*" Arch. Gen. de MeU," 1860. 



230 



PATHOLOGY OF THE FOETUS. 



Fig. 109. 



senting feeble signs of life, and which died in a short time, upon 
whom were found one hundred and thirteen fractures. The 
causes of such anomalies are not well understood, but are prob- 
ably due to arrested development of the bony structures. 

Intra-Uterine Amputations. — Another phenomenon equally 
remarkable, is that of complete or incomplete amputation of 
foetal extremities. Numerous cases of limbs deprived of a por- 
tion of their length, have been reported, the stump presenting 
evidences of traumatism. Cases are 
known in which the whole four extrem- 
ities were wanting. 

The cause of these conditions has re- 
ceived much attention. Beuss,* contrary 
to the opinions of some, believes that 
gangrene is not the cause of such so- 
lution of continuity, inasmuch as he is 
convinced that gangrene in the unrup- 
tured ovum is an impossibility, because 
there is no access of oxygen. 

The cause of this singular lesion is 
supposed by some to be due to coils of 
the umbilical cord around the limb, and 
this is likely the explanation in a small 
percentage of cases. The most common 
constriction exerted by fibrous bands, 
It should be remembered, how- 




Intra-Uterine Amputation. 



cause is probably the 
or by folds of the amnion, 
ever, that these bands are not always present, and the etiology 
of spontaneous intra-uterine amputation, is therefore rendered 
obscure. It seems clear that it is not always due to the me- 
chanical effect of a constricting agent, but in some cases it may 
arise from a deep-seated local lesion, and from the constriction 
exerted by extensive cicatricial action. 

The amputated part is sometimes found lying in the cavity of 
the amnion, and follows the child in delivery. More frequently 
the separated portion has disintegrated and disappeared. This 
can only occur, however, when amputation has taken place at an 
early period of development. When separation is effected at a 
later period, the part is not only found, but cicatrization of the 



* Scanzoni's Beitrage, 1869. 



DEATH AND KETENTION OF THE FCETUS. 231 

stump is often incomplete. Rudimentary toes are sometimes 
found on the stump, which are believed by some to be abortive 
efforts of nature at reproduction of the lost parts. 

Monstrosities.— Deviations from the ordinary process of de- 
velopment frequently result in the production of monsters. The 
subject is one which might very properly be considered here, 
but it is so extensive that we cannot attempt to give even its 
outlines. 

Death and Retention of the Fcetus. — Expulsion of the 
foetus does not, in all cases, immediately follow its death. If the 
placenta does not separate from the uterus, its vitality may re- 
main, its development continue, and expulsion thus be delayed. 
When the placenta does become separated, whether as cause or 
sequence of f cetal death, retention is probably due to diminished 
irritability of the reflex nervous centres which preside over the 
uterine energies. Retention due to uninterrupted utero-placen- 
tal relations, is rarely prolonged beyond the ordinary period of 
utero-gestation, while retention referable to diminished reflex 
irritability, may be indefinitely prolonged. Liebmann* believes 
that all cases of retention which exceed the normal term of 
pregnancy owe their continuance to such a cause. 

"When the foetus is retained, and the membranes continue in- 
tact, the most important changes are mummification, macera- 
tion, fatty degeneration, and calcification. If the membranes 
are broken, before or soon after f cetal death, mummification 
may result, or calcareous degeneration may follow. If air gains 
entrance into the uterine cavity, putrefactive changes are apt to 
take place. Mummification having been begun, putrefaction 
does not set in. 

Mummification. — It becomes necessary to explain what is 
meant by mummification, and what are its causes. " A mummi- 
fied foetus is flattened from compression. Its viscera are of soft 
consistency and of small dimensions. Its surface is f shrunken. 
The peritoneal and pleural cavities contain a scanty and discol- 
ored fluid. The subcutaneous areolar tissue has disappeared, 
and the skin lies in direct contact with the muscles. The pla- 
centa, which is dry, yellowish, and tough, is the seat of fatty de- 
generation, and contains the residue of old extravasations." 

* " Bietrag 2. Geburtsh, u. Gynaek," Bd., iii., 1874, p. 59, 63. 



232 PATHOLOGY OF THE FXETUS. 

It is most frequently observed in foetuses with inadequate 
blood-supply, a condition often growing out of constriction of 
the umbilical cord. From preference, it attacks foetuses dying 
during the middle stages of gestation, and especially a single 
foetus in twin pregnancy. "When one mummified and one living 
foetus occupy the uterine cavity, gestation usually preserves a 
tolerably normal course, and expulsion of the living and the dead 
is deferred until the close of the ordinary period of pregnancy. 

Maceration. — An embryo may be entirely dissolved by the 
process of mummification. In the case of the foetus, its general 
form, and the outline of its organs, are preserved, but granular 
degeneration and disintegration of their antatomical elements 
takes place. The epidermis is the first to yield to the process. 
It rises in the form of blisters, or vesicles, which are filled with 
a reddish, sero-sanguinolent, or a clear serous fluid. There is 
also infiltration of the corium, which has a brownish-red parch- 
ment-like appearance. The subcutaneous areolar and adipose 
tissues are also cedematous. Viewing the body as a whole, it is 
observed to be flaccid, and, from its cedematous condition, may 
be molded into curious shapes by pressure. The oedema is 
most apparent over the cranium, abdomen, feet, hands and 
sternum. The cranial sutures are separated, and the articular 
surfaces pushed apart. The periosteum is detached from the 
long bones. Dark blood is found in the vessels, and bloody se- 
rum in the serous cavities. The brain is pulpified, and all the 
viscera are softened. In some cases a species of fatty degenera- 
tion ensues. 

The placenta of a foetus undergoing maceration is almost des- 
titute of blood, soft, and easily broken, The cord is cylindri- 
cal, smooth, spongy, and inelastic. At the foetal end it is 
brownish-red and club-shaped. The liquor amnii has a sweet- 
ish and sickening, but not putrefactive odor. It is turbid, and 
of a greenish color, from admixture with it of meconium and 
sero-sanguinolent fluid. The membranes retain their strength 
and consistency for a considerable time, but finally swell, soften 
and darken. 

The rapidity with which the process of maceration proceeds 
varies within considerable limits, and no positive data concern- 
ing the time of foetal death are afforded by the changes which 
are observed. 



MOLES. 233 

Buge* says that macerated foetuses are expelled before the 
thirty-first week, in seventy-five per cent, of all cases. It is a 
significant fact that the presentation in nearly one-half of all 
such cases is either transverse or breech. 

Moles. — Of these, one variety — the hydatidiform — has al- 
ready been described, and of the other varieties, but a brief 
consideration will be required. Moles have been divided into 
two general classes, one of which is termed false, and the other 
true, the element of distinction between them being that the 
true mole is always consecutive on impregnation, and the false is 
not. Hence, in a work of this character and scope, we shall 
consider the former class only. 

True moles are divided into three general varieties, namely: 
1. The mole of abortion, or the blighted ovum. 2. The carne- 
ous, or fleshy mole ; and 3. The hydatidiform mole. The last 
of these having been described, the first two varieties only re- 
main for consideration. 

The Mole of Abortion, or mola sanguinosa, is the blighted 
ovum, within which post-mortem changes have just begun, and 
the mass has not yet been materially altered, save in the direc- 
tion of extravasation of blood and dissolution of the embryo, 
whose vital resistance, until death, had been sufficiently potent 
to preserve its integrity. Many years ago Smellie took occasion 
to say that "^should the embryo die (suppose in the first or sec- 
ond month), some days before the ovum is discharged, it will 
sometimes be entirely dissolved, so that when the secundines 
are delivered there's nothing more to be seen. In the first month 
the embryo is so small and tender that the dissolution will be 
performed in twelve hours ; in the second month, two, three, or 
four days will suffice for this purpose." In case foetal death 
occurs in more advanced pregnancy, degenerative and disinte- 
grative changes are wrought in a relatively short period, and the 
mass, when expelled, may not disclose its real character except 
to closest scrutiny. 

The Fleshy Mole.— The conditions which give rise to the 
formation of the carneous mole, are substantially as follows: 
As the result of some sudden or violent exertion, one or more 
blood-vessels give way, and as the blood is extravasated, it acts 

* " Zeit f. Geb. u. Gyn." Bd. i., Heft. 1, 1877, p. 58. 



234 DISEASES AND ACCIDENTS OF PREGNANCY. 

in a mechanical way to- influence separation of contiguous parts, 
with most potent results. The embryo perishes from want of 
nutritive supplies. A similar effect may be produced by apo - 
plexy of the placenta, elsewhere considered. Extravasation is 
sometimes between the chorion and decidua, and even within the 
amniotic cavity, and results in embryonic death. 

Consecutive on such occurrences there is, most frequently, 
speedy expulsion of the ovum, but occasionally it remains for a 
considerable time, and undergoes certain changes by which it is 
converted into a fleshy mass. The effused blood becomes decol- 
orized, the blanching proceeding from centre to circumference, 
and, according to Scanzoni, the fibrin is transformed into cellular 
tissue, by which means communication is established between 
the external lining of the ovum and the uterine tissues, — and 
thus further development is made possible. It is highly proba- 
ble that complete separation of the ovum from the uterus never 
takes place in these cases, but, through the adherent parts, 
vascular communication is continued and amplified. Degener- 
ative changes take place chiefly in the decidua vera, though the 
chorion and amnion are sometimes more or less involved. 

These masses seldom exceed an orange in size, but their full 
development, from the very nature of the case, is quite rapidly 
accomplished. They may continue in utero for three or four 
months, but eventually the organ is excited to contraction, and 
expulsion takes place, unattended, as a rule, by any remarkable 
symptoms. 

There is little or no treatment required. In expulsion, the 
case assumes the character of an abortion, and similar principles 
of treatment should be adopted. 



CHAPTEK X. 

Diseases and Accidents of Pregnancy. 

When we reflect upon the profound impressions made upon 
the female organism, and the extensive changes wrought in it 



HYGIENE OF PREGNANCY. 235 

by pregnancy; furthermore when we recollect that this condi- 
tion exempts a woman from but few of the ordinary ills of life, 
we will cease to wonder that there is a pathological, as well as 
physiological, side of the subject. 

The Hygiene of Pregnancy. — At the risk of transposing 
the conventional order of discussing pathological states, we here 
insert a few observations on the general management of the 
pregnant state. The importance which attaches to the obser- 
vance of sanitary rules during pregnancy, has not received 
enough attention. The augmented elimination through the 
lungs of carbonic acid, necessarily increases the demands for 
oxygen, and the acceleration of respiration, makes an abundance 
of fresh air a matter of the highest importance. To confine 
a pregnant woman within the bounds of a few rooms, with an 
occasional walk or drive outside, is unwise, if not cruel. So far 
as her necessary duties, her physical strength, and the weather 
will permit, she should spend her days very largely in the open 
air, and her nights in well-ventilated rooms. 

The diet must be regulated to suit the peculiar requirements 
and sensibilities of the individual woman, but should embrace 
most nutritious, easily-digested, articles of food. The stomach 
is rarely in a condition to profit from the eating of pastry and 
confections, and they should be scrupulously avoided. Women 
ought not to suffer themselves to be led into eating what to a 
reasonable mind must seem harmful, by what are termed "long- 
ings," and no possible effect on the foetus can result from self- 
denial. A good appetite, indulged by the supply of a reason- 
able quantity of wholesome food, is the best guarantee of a 
healthy and well-formed child. A voracious appetite should be 
restrained, and a feeble one encouraged. 

Next in importance to fresh air and good food stands physical 
exercise. This should not be violent, nor carried to fatigue. 
Walking in the open air, and riding in an easy vehicle will aid 
digestion, and induce refreshing sleep. In the case of women 
who have formed the habit of aborting at a certain stage of 
pregnancy, rest should be enforced until the dangerous period 
has passed. It has been found that there is often a predisposi- 
tion to abortion at the time when, but for interruption, the 
menstrual return would have been experienced, and hence this 
is a period during which special precaution should be observed. 



236 DISEASES AND ACCIDENTS OF PREGNANCY. 

Sexual pleasures ought to be indulged in strictest moderation. 

The free, but judicious use of water is beneficial. Frequent 
sponge baths, followed by brisk rubbing, will keep the skin in 
good condition, and give tone to the entire system. The yaginal , 
douche may be employed, but the stream should be feeble, and 
the quantity of water used at one time not in excess of a pint. 

The entire period of utero-gestation in some women is one of 
physical and mental distress, and every effort should be made 
to lighten the load of suffering. The ailments from which they 
suffer are various, sometimes relievable by medication, at other 
times yielding to a change of scenery or circumstances; while 
in certain instances they will not relax their hold despite every 
effort to dislodge them. 

Derangements of the Digestive System. — The most prom- 
inent derangements of the digestive functions, referable chiefly 
to sympathetic irritation, are nausea and vomiting. They are 
the common accompaniments of pregnancy, and under ordinary 
circumstances can hardly be considered as ailments requiring 
medical attention; but occasionally they are so excessive and 
long continued as to lead to inanition, extreme debility, and 
even death. In some cases the sickness is limited to the morn- 
ing hours, at which time the smallest quantity of food is rejected, 
while later in the day it may be borne with impunity. From 
this circumstance the nausea and vomiting of pregnancy have 
been designated "morning sickness." In other cases, the wo- 
man feels constantly sick, and the mere smell of food may bring 
on a paroxysm of vomiting. 

This distressing accompaniment of pregnancy is not experi- 
enced by all women, but about forty per cent, of them escape it 
altogether. It usually begins about the sixth week, and contin- 
ues till the close of the third month. Sometimes, however, it 
immediately follows conception, and continues until the end of 
pregnancy, while in other women it does not appear until the 
patient has reached the latter months of gestation. 

It is surprising to observe how severe and protracted may be 
such gastric disturbances in some cases, without producing 
emaciation or excessive debility. In other instances the vital 
forces are thereby brought to a low ebb. Grave cases are char- 
acterized by a dry coated tongue, palor and distress of counte- 
nance, excessive nervous irritability, tenderness of the epigastrium, 



NAUSEA AND VOMITING OF PREGNANCY. 237 

great restlessness, and general heat. In worse cases there is 
elevated temperature, with rapid, small and thready pulse. 
Want of nourishment soon reduces the woman to a state of ex- 
treme emaciation. The breath becomes fetid, and the tongue 
dry and black. Profound exhaustion, with low delirium follows, 
and, in the absence of relief, death soon ensues. 

The Prognosis in nausea and vomiting of pregnancy, though 
the affection should assume a grave form, is generally hopeful; 
but such cases create much anxiety. Gueniot collected 118 
eases of this form of the disease, out of which forty-six died; 
and out of the seventy-two that recovered, in forty-two the symp- 
toms only ceased when abortion, either spontaneously or artifi- 
cially induced, had occurred.* Upon the termination of preg- 
nancy the symptoms sometimes cease at once, and the digestive 
and assimilative processes soon become active and vigorous. 

Treatment. — It is of prime importance to regulate the diet 
of women suffering from morning sickness. A few mouthfuls 
of food, or a weak cup of coffee, taken in the morning before 
rising, is sometimes of decided benefit. Food should be taken 
in small quantities, and at short intervals. Ice cream thus eaten 
will sometimes be retained when nothing else can be. Kou- 
myss, when fancied by the patient, is a remarkably good food. 
Barley-water, oatmeal gruel, blanc-mange, beef, mutton, and 
chicken broth, and essence of beef in small quantities, are 
among the articles from which selections should from time to 
time be made. The caprices of the woman should have an in- 
fluence over the choice of food, but should not be permitted to 
betray one into unwise action. 

Change of Habitation, Air and Scenery. — In some cases, 
where other forms of treatment prove unavailing, and the 
patients are greatly reduced, a change of habitation, air and 
scenery, especially from a poorly-ventilated house, in the crowd- 
ed part of a city, to a rural situation, is of the greatest benefit. 

Local Treatment. — Since it is clear that the nausea and 
vomiting of pregnancy are mainly dependent upon changes go- 
ing on in and about the uterus, the attempt has been made to 
reduce the irritability of the organ by local treatment. Morphia 

*PLAYFAIR. "System of Midwifery," Am, Ed., 1880. p. 189. 



238 DISEASES AND ACCIDENTS OF PREGNANCY. 

in the form of suppositories, and belladonna applications to the 
cervix, have been recommended, the former being in some cases 
of apparent benefit. The cervix has been burned with caustic, 
and bitten by leeches, in the vain endeavor to overcome the ob- 
stinate sickness. In the latter months, gentle dilatation of the 
cervical canal, to a slight degree only, has been attended with 
beneficial results. Dr. Grailey Hewitt believes that in quite a 
large percentage of cases the disorder depends upon uterine de- 
viations, and can be cured only by rectification. This may be 
true, and the suggestion should lead to a careful examination 
in all obstinate cases. If retroverted, a Hodge, or Albert Smith, 
pessary, properly adjusted, may be safely worn. During the 
employment of local treatment the woman should be required to 
rest more than usual in the reclining posture. 

Electricity has, in some cases, afforded relief to the distress- 
ing nausea and vomiting of pregnancy. Both the continuous 
and interrupted currents have been employed. 

Medicinal Treatment.— The list of remedies which may be 
found serviceable in the treatment of the nausea and vomiting 
of pregnancy is long; but there are a few which are especially 
prominent. These are: 

Ipecac, when the nausea is the predominantly distressing 
feature, attended with vomiting of bilious matters, undigested 
food, and large quantities of mucus. 

Arsenicum, when the vomiting occurs after eating and drink- 
ing, and there is faintness, and excessive prostration of the vital 
forces. 

Nux vomica, for real morning sickness; bitter, sour eructa- 
tions; vomiting of sour mucus, and the ingesta. Also, for ex- 
cessive nausea, with the feeling that she would be better if she 
could vomit. 

Tabacum, in those cases where there is nausea, with faintness 
and deathly pallor, relieved by being in the open air. Vomit- 
ing of water, acid fluid, and mucus. 

Pulsatilla, especially when the vomiting comes on in the 
evening, or night. The appetite is capricious, the woman crav- 
ing beer, acids, wines, etc. Much eructation, tasting of the in- 
gesta. Specially suited to mild, tearful women. 

Acetic acid, when there is sour belching and vomiting, with 
profuse waterbrash and salivation. 



NAUSEA AND VOMITING OF PREGNANCY. 239 

Cokhicum, in cases when the symptom is well marked of ex- 
cessive nausea, even to f aintness, produced by the odor of fish, 
eggs, meats, etc. 

Bryonia, when the nausea and vomiting are brought on or de- 
cidedly aggravated by the least motion. Veratrum album is 
well suited to the same symptom. 

Phosphoric acid (dilute), a few drops in a half -glass of water, 
a teaspoonful every two hours, is often of great service. Its 
special indications are similar to those given above for acetic 
acid. 

Almost every remedy in the Materia Medica has been recom- 
mended, and we doubt not that there are cases to which they 
may severally be suited. 

The Production of Abortion. — When the vomiting is abso- 
lutely uncontrollable — as it will rarely prove to be when the 
patient fully co-operates with her physician in the effort to cure 
— and fatal results seem imminent, there remains, as an ultimate 
resource, the artificial interruption of pregnancy. Regard must 
be had, however, for the clinical fact that in most instances the 
threatening symptoms disappear at about the close of the third 
month. It is an operation which always subjects the physician 
to criticism, and as it is attended with considerable risk, it 
should never be undertaken upon the responsibility of the at- 
tending physician alone. 

There seems to be no doubt that a few mothers have been 
saved by the induction of labor in such cases, and in all proba- 
bility many have been lost for want of it. The success of the 
operation demands that it be performed before prostration has 
become so great that the patient cannot rally. The obvious in- 
tention is to diminish uterine tension without delay, and the 
preferable mode of doing this is to puncture the membranes 
with a uterine sound or stiff catheter, and allow the amniotic 
fluid to escape. 

Prof. C. Braun,* of Vienna, reports a case of hyperemesis, to 
which he was called, in which the woman was supposed to be 
moribund. The physician in charge had resolved on the induc- 
tion of premature labor as a last resort. Dr. Braun decided to 
bathe the intra-vaginal portion of the cervix in a ten per cent. 

* " Allgem. Wein. Med. Zeit.," 1882. 



240 DISEASES AND ACCIDENTS OF PREGNANCY. 

solution of nitrate of silver. This was done, and the surface 
quickly dried, to prevent further cauterization. An hour after- 
wards the patient enjoyed and retained a meal of roast veal, and 
there was no subsequent vomiting. Prof. Braun says he has 
never, in all his vast obstetrical practice, seen a case of death 
from hyperemesis. In France, where abortion is frequently in- 
duced for the relief of these symptoms, the vomiting is arrested 
in only about forty per cent, of all cases, while ten per cent, of 
them terminate fatally. 

Other Gastric Disorders.— Anorexia, or want of appetite, 
and even a loathing and disgust for food, is a prominent disorder 
of the stomach, especially during the early months of gestation; 
but under the influence of gentle exercise, pure air, salubrious 
surroundings, and judicious selection of food, it will generally 
disappear. The remedies which are most likely to afford aid are 
nux vomica, ipecac, tartar emetic, natrum muriaticam, colchicum, 
and putsalilla. 

The patient may also be annoyed with acidity of the stomach 
and heartburn, for which nux vomica, calcarea carb., natrum 
muriaticum, sulphur, or phosphoric acid is likely to prove effica- 
cious. Temporary relief will often be afforded by a swallow of 
pure glycerine, or a half teaspoonful dose of aromatic spirits 
of ammonia. Flatulent distension may be removed by carbo 
veg., china, lycopodium, nux vomica, or argentum nitrium. Neu- 
ralgia of the stomach is sometimes very distressing. If attended 
with nausea, ipecac will often relieve; if of a cramping nature, 
nux-vomica; if the stomach feels as though distended by gas, 
carbo veg. Belladonna, or better still, atropine, is often of ser- 
vice. Hot fomentations should be applied to the epigastrium, 
and, if relief is not obtained in response to the treatment given, a 
minimum dose of morphia may be given hypodermically. 

The caprices of appetite so frequently observed do not often 
require medication. 

Ptyalism, or excessive flow of saliva, is occasionally asso- 
ciated with pregnancy. In a few cases the secretion has amounted 
to two or three quarts in the course of a day. The remedies 
best calculated to relieve, are mercurius, carbo vegetabelis, acetic 
acid, belladonna. If there is disgust for food, and vomiting of 
mucus, tartar emetic. 



PRURITUS. 241 

Pruritus. — Distressing itching, without a visible affection of 
the skin, sometimes torments pregnant women beyond all en- 
durance. The affection may be limited to the distended ab- 
dominal walls; in other cases the vulva and vagina are the seat 
of the itching. In many instances, it is doubtless a reflex ner- 
vous symptom, in others, it depends on an irritating vaginal 
discharge, and again, on ascarides. When the vulva and vagina 
are the parts involved, the vagina should be syringed out twice a 
day with a solution of carbolic acid or borax, and the vulva 
washed with the same. If dependent on ascarides, a wash 
composed of an infusion of tobacco, or garlic, may be used. 
When the abdominal surface is the seat of the trouble, tempo- 
rary relief may be obtained from the local use of chloroform 
liniment, or a solution of carbolic acid. The principal remedies 
are borax, (which should be used both locally and internally,) 
conium, platina, and sepia. 

Face-ache. — Neuralgia of the fifth nerve is often experienced, 
and atropine, belladonna, arsenicum, or gelsemium, will generally 
relieve it. Should the indicated remedies fail to afford relief, 
resort may be had to the external application of aconite, chloro- 
form, or camphor liniment. The continued use of hot water is 
sometimes a great aid. 

Cephalalgia. — The remedy may be selected according to the 
following symptoms : Bursting or splitting headache, — bryonies 
Awakens every morning with a violent bursting headache, — na- 
trum mur. Sense of great fullness of the head, — belladonna. 
Head feels much too large, — nux vomica, gelsemium, aconite, 
glonoinum. Fullness and heaviness in the forehead, — belladonna, 
bryonia alb. Determination of blood to the head, with throb- 
bing headache, — belladonna. Sensation of great expansion, 
chiefly of head and face, — argentrum niiricum. Pressing head- 
ache from both sides, as if the head were in a vice, — mercurius. 
Dreadful pain in the vertex as if the brain were crushed, after 
long-continued grief, — phosphoric acid. Piercing, throbbing 
pain in the forehead, worse from motion, — aconite. Pain of a 
dull, heavy, throbbing character, mainly in the forehead, worse 
after eating, — kali bich. Beating headache, most violent over 
the eyes, — lachesis. Throbbing headache after excessive deple- 
tion, — china. Headache from eating a little too much, — nux 
moschata. Beating headache, seemingly in the middle of the 



242 DISEASES AND ACCIDENTS OF PEEGNANCY. 

brain, — calcarea carb. Beating headache in the occiput, — sepia. 

Insomnia. — Continued sleeplessness is not only distressing to 
the patient, but it is liable to so reduce her vital energies that 
she is poorly prepared to undergo the violent strain of labor. 
Moderate exercise, pure air and frequent baths, will generally 
bring the needed repose. Certain remedies will aid: 

Sleeplessness, — actcea rac, hyoscyamus, coffea, caulophyllum. 

Sleeplessness and restlessness, — aconite, arsenicum album. 
Drowsy during the day, sleepless at night, — sulphur. Cannot 
sleep after 3 a. m., ideas so crowd on the mind, — nux vomica. 
Cannot sleep after 3 A. M., — calcarea carb. Cannot sleep because 
of involuntary thoughts, — calcarea carb., china. Sleepy, but 
cannot sleep, — belladonna. 

Blood Changes of Pregnancy.* — The most important changes 
consist in the loss of red corpuscles and albumen. The former, 
as the oxygen carriers of the tissues, are illy spared from the 
economy. When they have undergone destruction to any ma- 
terial extent, the cell elements, whose vitality is intimately asso- 
ciated with the power to take oxygen from the blood, suffer from 
inanition, and the starved cells waste, or fill with fatty molecules. 
These changes are of necessity followed by loss of weight, mus- 
cular prostration, impaired functional activity of the secretory 
organs, and increased nerve irritability. As a consequence, the 
appetite fails, the digestion is weakened, neuralgic pains develop, 
and even moderate muscular exertion is attended with effort, and 
followed by a sense of fatigue; vertigo, loss of memory, and, in 
severe cases, chorea, hysteria, and insanity, may result from the 
deranged condition of the nerve centres; attacks of syncope, 
palpitations, and precordial oppression point to a feeble heart 
action; the arterial tension is lowered, and venous hyperemia 
results; and finally, the stagnant blood, deprived of its albumen, 
in place of inviting endosmotic currents, transudes through the 
walls of the vessels, giving rise to oedema and dropsical effusions. 
Gusserowf (1871) called attention to the fact that the anaemia 
of pregnancy might progress to such an extreme as to produce 
a fatal termination. 

The Treatment of anaemia is largely prophylactic. Light, 

*Lusk. " Science and Art of Midwifery," p. 116. 

f " Ueber hochgradigste Ansemie Schuangerer." " Arch. f. Gynaek." Bd. ii, 
p. 218. 



BLOOD CHANGES OF PREGNANCY. Z4,6 

air, moderate exercise, good food, regulation of the bowels, 
cheerful society, and an occasional respite from household and 
family cares, will always be the main checks to its extreme de- 
velopment. In weakened states of the stomach, when the latter 
revolts at beefsteak and mutton, easily assimilated albuminoid 
articles, such as milk, soft-boiled eggs, and scraped raw, or un- 
derdone, meat, should be administered in small, but frequently 
repeated portions. Where the marasmus becomes extreme, and 
the rectum is tolerant, the stomach may be relieved of a part of 
its duty by the use of nutritive enemata. In the pernicious 
form of anaemia, Gusserow tried transfusion, but without suc- 
cess. He therefore recommended a resort to premature labor. 
The pernicious form of anaemia, though not confined to multi- 
parae, develops most frequently in women who have borne many 
children in rapid succession. 

A not unusual result of hydraemia consists in swelling of 
the lower extremities, beginning at the ankles, and thence ex- 
tending upward, and often invading the labia, the vagina, and 
the lower segment of the uterus. When not associated with 
kidney complications, this oedema is rarely dangerous, though 
often the source of extreme discomfort. In some cases of oede- 
ma of the vulva, the labia may attain to the size of a man's head, 
and become nearly diaphanous from the serous infiltration. 
When the distention is extreme, gangrene may threaten, and 
make puncture necessary. If free drainage is established, the 
swelling rapidly subsides. 

(Edema of the lower extremities seldom disappears entirely 
before confinement, though relief is sometimes experienced in 
the last month, when the fundus of the uterus falls forward. 
Slight degrees, such as swelling limited to the feet, making it 
necessary for the woman to go around in large shoes, do not re- 
quire treatment. When, however, the skin of the limbs becomes 
tense and painful, warm cloths should be applied, diaphoresis, if 
possible, should be induced, and the patient be kept in a recum- 
bent position, or sit with the extremities raised. 

The medicinal treatment consists in the administration of one 
or more of the following remedies, maintained for a considera- 
ble time, since beneficial effects are not at once manifested. 

Ferrum, in one of its several forms, is most frequently em- 
ployed with good results. The metallicum is often used, as well 



24A DISEASES AND ACCIDENTS OF PREGNANCY. 

as ferrum et strychnia citratse, and ferram phosphoricum. 

Pulsatilla is capable of affording aid in these cases, especially 
when the attack is of the milder type. There is constant chilli- 
ness, coldness, and paleness of the skin; coldness of the feet; ir- 
regular pnlse, and palpitation of the heart; want of appetite; 
vertigo, especially on rising; mild, weeping mood, or excessive 
irritability. 

Nux vomica, when indigestion is a troublesome feature, and 
there is constipation, or small loose stools, with urging. 

Numerous other remedies will be found useful, such as helo- 
nias, phosphorus, cyclamen, calcarea carb., sulphur, etc. 

For the dropsical symptoms, we will find help in arsenicum 
album, apis met, helleborus, or apocynum can. When limited to 
the feet and legs, bryonia may be the remedy. 

Albuminuria. — Acute Bright s Disease. — Albuminuria, asso- 
ciated with pregnancy, was little known by the profession until 
within about thirty years. Eoger, in France, and Lever, in 
Great Britain, were the first to direct attention to its intimate 
relationship to that appalling complication of pregnancy and 
puerperality, viz: eclampsia. For many years it was believed 
that convulsions occurring in the pregnant or puerperal woman 
were always preceded by, and in a measure dependent upon, al- 
buminuria. But recently it has been shown that this is not 
true, for in some cases albumen is not present in the urine 
until after the convulsions have begun; while in other cases it 
does not appear at all. 

Albuminuria is also associated with other affections to which 
the pregnant woman is subject — as, for example, puerperal 
mania, vertigo, headache, and certain forms of paralysis, either 
of the nerves of special sense, as in the instance of amaurosis, 
or of the spinal system. The relation which it bears to these 
diseases is not yet fully understood. It should always be re- 
garded with apprehension, and vigorous efforts made for its 
removal. 

Causes. — Albuminuria in a pregnant woman is not a rare oc- 
currence. Blot and Litzman met with it in twenty per cent, of 
all cases examined, which is, however, far above the estimate of 
other authors. Dr. Fordyce Barker thinks it occurs in about 



ALBUMINURIA. 245 

one out of twenty-five cases, or four per cent.,* and Hofmeirf 
found it in 137 out of 5,000 women delivered in the Berlin 
Clinic, which represent about 2.74 per cent. In most cases it 
disappears soon after delivery, and hence the causes upon which 
it depends must be temporary. It follows, therefore, that albu- 
men in the urine of a pregnant woman, while it justly arouses 
considerable anxiety, does not always assume the grave import- 
ance that it does in the non-pregnant state. Lohlein, from the 
record of thirty-two autopsies made upon eclamptic women, 
found in eight that dilatation of one or both ureters co-existed 
with renal disturbances. How far this has a bearing on the de- 
velopment of uremic manifestations remains to be seen. 

The blood changes already described as taking place in preg- 
nancy, may have a causative relationship to albuminuria. Still, 
it is observed that in the worst cases of anaemia during gestation, 
albumen is rarely found in the urine. 

It is supposed by some that albumen in the urine is due to 
congestion of the venous circulation of the kidneys, caused by 
mechanical pressure of the renal vessels by the gravid uterus. 
This may be true of some cases, but, in general, it cannot be re- 
garded as the only, or the chief cause, as similar pressure is ex- 
erted by uterine and ovarian tumors without producing such an 
effect. 

Symptoms. — One of the most common symptoms of albumin- 
uria is anasarca, which is a dropsical condition of the subcuta- 
neous cellular tissues. This is especially manifest in the ex- 
tremities, and face, and sometimes becomes excessive. (Edema- 
tous swelling of the feet and legs is observed in a large propor- 
tion of pregnant women, though it is associated with the albu- 
minuria in only a small percentage of cases. Sometimes the 
anasarca spreads until it finally becomes general, and the woman 
presents a pitiable -aspect. 

There are also many nervous symptoms connected with albu- 
minuria, such as vertigo, cephalalgia, dimness of vision, spots 
before the eyes, and nausea. The appearance of such symp- 
toms in a pregnant woman, whether there be coincident oedema, 
or not, should elicit a thorough examination of the urine both 
chemically and microscopically. 

* Am. Jour. Obs., July, 1878. 
f Berlin Klin. Woch., Sept., 1878. 



246 DISEASES AND ACCIDENTS OF PEEGNANCY. 

The Effects of Albuminuria. — The various diseases associ- 
ated, either as cause or effect, with albumen in the urine, require 
separate consideration, inasmuch as some of them are among 
the most dangerous complications to which a pregnant woman 
is liable. Some of these have been alluded to as symptoms of 
albuminuria, such as cephalalgia, vertigo, and paralysis ; but that 
which stands out most prominently is eclampsia. The precise 
mode in which the last named disease is produced will be con- 
sidered when we come to discuss in detail the cause, course and 
treatment of it in another chapter. 

Prognosis. — The danger to mother and child in connection 
with albuminuria in pregnancy is not slight. Goubeyre esti- 
mated that forty-nine per cent, of primiparae who manifest the 
diseased condition, and who escape eclampsia, die from morbid 
results traceable to the albuminuria. Hofmeir found that out 
of forty-six cases reported by him, only one-third had eclampsia, 
though one-half died. Including both acute and chronic cases, 
Braun estimates that only sixty in the hundred develop uraeniic 
convulsions. Hofmeir found in five thousand births recorded 
upon the books of the Berlin Clinic, 137 cases of nephritis en- 
tered. Out of this number only 104 patients were attacked with 
eclampsia. Prof. Bamberger* reports from autopsies of the 
"allgemeinen Krankenhaus," in twelve years, 2,430 cases of 
Bright's disease, of which 152 were found in puerperal and 
pregnant women, viz: 80 acute cases, 56 chronic cases, and 16 
cases of atrophy. Puerperal eclampsia was recorded in 23 of 
them. 

A modifying condition has been shown by Bailly to exist, viz: 
that not rarely albuminuria in pregnant women disappears 
for several hours, and then reappears, so that it may happen that 
an examination is made during the short period when the urine 
ceases to be albuminous. It should be borne in mind, however, 
that it is the renal insufficiency, and not the albuminuria which 
causes uraemia and convulsions. The mere absence of albumen 
from the urine does not even exclude the existence of Bright's 
disease. 

Convulsions occur more commonly in primiparae than in mul- 
tipara, especially in elderly primiparae, in twin pregnancies, in 

* " Ueber Morbus Brightii und seine Bezichnngen zu anderen Krankheiten," 
Volkman's Samml. Klin. Vortr.," No. 173, p. 1541. 



ALBUMINUEIA. 217 

women with contracted pelves, and in connection with the de- 
livery of male children. They may occur epidemically in con- 
sequence of atmospheric conditions, which probably interfere 
with the functions of the skin, and thus indirectly increase the 
labor thrown upon the kidneys. 

Tendency to Produce Abortion.— Besides the risk which 
accrues to the mother from the liability to eclampsia, albuminu- 
ria strongly predisposes to abortion, no doubt on account of the 
imperfect nutrition of the foetus by blood impoverished from the 
drain of albuminous materials through the kidneys. This fact 
has been observed by many writers. A good illustration of it is 
given by Tanner,* who states that out of seven women he at- 
tended, suffering from Bright' s disease during pregnancy, four 
aborted, one of them three times in succession. 

Character of the Urine. — Contrary to the common belief 
among patients, the mere physical appearance of the urine as 
regards cloudiness, ropiness, etc., has very little significance, so 
far as concerns the presence of albumen. The urine is generally 
scanty, and highly colored, and, in addition to the albumen, es- 
pecially in cases where the morbid condition has existed for 
some time, we may find epithelial cells, tube casts, and occa- 
sionally, blood corpuscles. 

Treatment. — In order to gain the best results from the treat- 
ment of puerperal albuminuria, and prevent so far as possible 
the occurrence of impending convulsions, it becomes the duty of 
the medical attendant to examine closely every case which pre- 
sents suspicious symptoms. In the greater share of cases, how- 
ever, he is not consulted until eclampsia has attacked his patient, 
or she is in parturition. 

The treatment must of course be modified to meet the various 
indications presented by individual cases. The stage of the 
reproductive process in which she is, namely, — pregnancy, labor 
or puerperality, the severity of the symptoms, and the cause of 
.them, are all important considerations. If the cause of the 
albuminuria is traceable to pressure of the gravid uterus on 
surrounding organs, thereby producing hyperemia of the renal 
secretory apparatus, treatment ought to be varied in some es- 
sentials from that which would be employed when albumen in 

* " Signs and Diseases of Pregnancy," p. 428. 



248 DISEASES AND ACCIDENTS OF PREGNANCY. 

the urine is referable to a different canse. Again, a slight trace 
of albumen, with no pending constitutional disturbances, would 
not require the same heroic treatment that might be indicated 
when convulsions threaten the patient's life. 

Homoeopathy has provided us with remedies which have a 
most salutary effect on this disease. Among them mercurius 
corrosivus occupies the highest place. Prof. R. Ludlam * says 
of it, " Experience has led me to place great confidence in the 
mercurius corrosivus. I have prescribed it very frequently to 
fulfill this precise indication, and it has seldom disappointed 
me# " * * * « The idea which I design to convey is not that 
this, or any other remedy, is an absolute specific for ante-par- 
turn convulsibility. There is no real prophylactic of puerperal 
eclampsia. But if in one case in ten you can recognize incipi- 
ent symptoms of this dreadful disease, and avert it, you should 
know how to do it." 

Arsenicum is often a valuable remedy. The oedema is obser- 
vable in the face, especially about the eyes; the countenance is 
pale, and the thirst intense. 

Apis is indicated by similar symptoms, but there is generally 
absence of thirst. 

Phosphoric acid and apocynum cann., have also been used 
with benefit. The latter may be given with better effect by hy- 
podermic injection, the fluid extract being employed. f 

Besides these remedies might be mentioned helleborus, tere- 
binthina, phosphorus, and many others. 

The Advisability of Induced Labor.— In obstinate cases, 
the question of inducing labor, as a means of relief, is forced 
upon us. Hofmeir is in favor of the operation, and believes 
that it does not increase the risk of eclampsia, while it may 
altogether avert an attack. It has been advocated by others. 
On the other hand, Spiegelberg is opposed to it, and Fordyse 
Barker J thinks it should only be resorted to " when treatment 
has been thoroughly and perseveringly tried without success for 
the removal of symptoms of so grave a character that their con- 
tinuance would result in the death of the patient." Playfair§ 

* "Diseases of Women." 1881, p. 298. 

J Fahxestock, "The clinique," vol. 1, p. 321. 

| : 'Am. Jour. Obs." July, 1878. 

\ "System of Midwifery," p. 201. 



CHOREA DUKING PREGNANCY. 249 

says: "It is riot easy to lay down any definite rules to guide 
our decision; but I should not hesitate to adopt this resource in 
all cases in which the quantity of albumen is considerable, and 
progressively increasing, and in which treatment has failed to 
lessen the amount; and, above all, in every case attended with 
threatening symptoms, such as severe headache, dizziness, or 
loss of sight. The risks of the operation are infinitesimal com- 
pared to those which the patient would run in the event of puer- 
peral convulsions sepervening, or chronic Bright' s disease 
becoming established. As the operation is seldom likely to be 
indicated until the child has reached a viable age, and as the 
albuminuria places the child's life in danger, we are quite justi- 
fied in considering the mother's safety alone in determining on 
its performance." 

Chorea During Pregnancy. — Chorea gravidarum. — This is 
fortunately a rare complication, and occurs chiefly in young, 
highly-nervous women, a large percentage of whom have had 
chorea in childhood. It is occasionally hereditary. Anaemia is 
a frequent cause. Sudden emotions and repercussed eruptions 
sometimes induce it. The mere irritation proceeding from nor- 
mal development of the ovum, in certain susceptible women may 
constitute a sufficient cause. 

Its prognosis, under suitable treatment, does not appear to be 
so gloomy as some writers would lead us to suppose. Still, it 
must be regarded as a grave affection. Dr. Barnes* compiled 
fifty-six cases, of which seventeen died. Its danger is not to life 
alone, for it appears that chorea is more apt to leave permanent 
mental disturbance when it occurs during pregnancy, than at 
other times. It has also an unquestionable tendency to bring- 
on abortion or premature labor, and generally to sacrifice the 
life of the child. 

Treatment. — The patient must be protected from all possible 
sources of irritation, and her surroundings rendered as pleasant 
and agreeable as may be. Good food, fresh air, regular baths, 
followed by brisk rubbing, and such exercise as she is able to 
take, are the general indications for treatment. Prof. Ludlamf 
says, " there are nervous conditions which simulate chorea, that 

* " Obstet. Trans.," vol. x. 

f " Diseases of Women," 1881. p. 324. 



250 DISEASES AND ACCIDENTS OF PREGNANCY. 

yield readily to such remedies as belladonna, ignatia, coffea, mix 
vomica, agaricus, and cuprum, under appropriate indications. 
These states are temporary, and often depend upon avoidable 
causes. They are easily cured." 

Spasms of chorea, caused by fright, require aconite, ignatia, 
opium or cuprum. 

When proceeding from suppressed eruptions, cuprum aceti- 
cum, sulphur, calcarea carb., arsenicum and causticum are the 
remedies from which selection should be made. 

When traceable to no special cause, the remedies from which 
to choose are mainly veratrum viride, belladonna, Pulsatilla* 
sepia, sabina, gelsemium and caulophyllum, the particular indi- 
cations for which will be found in the mental and physical traits, 
and collateral manifestations. Anaesthetics are to be used only 
as temporary palliatives, and rarely, even for this purpose, save 
in the latter weeks of pregnancy. 

If, in spite of our remedies, the paroxysms increase in severity, 
and the patient's strength appears to be exhausted, counsel 
agreeing, labor may be induced. Evacuating the uterus gener- 
ally soon concludes the choreic manifestations. 

The tendency to recurrence of chorea in successive pregnan- 
cies should not be forgotten, and every precaution ought to be 
observed to prevent its development. 

Hysteria. — Authors do not say much about hysteria in preg- 
nancy, except in its graver form of convulsions, yet it is by no 
means infrequent in the early part of gestation. It is at this 
stage, too, that hysterical convulsions are most frequent. In- 
digestion, excessive fatigue, or loss of sleep may bring on hys- 
terical manifestations in the pregnant woman. 

Mere remedies, however well-suited to the ease, are hardly 
sufficient. The disorder being chiefly emotional, the patient's 
mind has to be brought under subjection, not by harsh, but by 
the gentlest possible means. Anything which is calculated to 
strike the fancy, to divert, overwhelm or control the emotional 
faculties, will have a beneficial influence. These are exceedingly 
difficult cases to handle, and demand the exercise of the best 
judgment, and keenest tact. The proper employment of friction, 
electricity, animal magnetism, bathing and exercise, is to be 
recommended. Electricity ought to be used with great caution, 
for fear of exciting uterine action. 



PARALYSIS AND SYNCOPE. 251 

Among the remedies most frequently called for are ignatia, 
nux moschata, gelsemium, belladonna, caulophyllum, secale, 
plumbum, moschus, and nux vomica. The treatment between 
paroxysms must be regulated by the nature of the case. 

Paralysis. — Pregnant women seem to be more liable to the 
various forms of paralysis than the unimpregnated. The sub- 
ject, however, is too extensive for anything more than brief 
mention here. In a general way it may be said that the disease 
seems in many cases to be associated with albuminuria, and con- 
sequent on uraemia. 

Treatment. — Most modern authorities recommend that when 
paralysis makes its appearance in a pregnant woman whose urine 
is loaded with albumen, that premature labor be induced without 
delay. The cause once removed, the paralysis usually disappears 
in a few hours or days. If it should persist, the induced cur- 
rent, conjoined with friction, bathing, and the suitable homoe- 
opathic remedies will generally be effectual. For the relief of 
paralysis not associated with albuminuria, the induction of pre- 
mature labor would be manifestly improper. 

The result of homoeopathic medication in the treatment of albu- 
minuria, are in the main, so satisfactory, that the cases of paral- 
ysis dependent on its existence, which demand for their relief 
the induction of premature labor, are few. The remedies of 
greatest service have already been given under the head of albu- 
minuria. If we are driven to the induction of labor, or, if it 
comes on naturally, without subsequent relief of the paralytic 
condition, the remedies which will be most beneficial are nux 
vomica, gelsemium, sulphur, and calcarea carb. 

Syncope. — Pregnant women are remarkably subject to attacks 
of faintness at various periods of gestation, but more especially 
during the first half of that state. The syncope is not often 
very pronounced, and hence consciousness is seldom entirely lost. 
The patient, however, may lie with dilated pupils, feeble pulse, 
and partial unconsciousness for several minutes, or much longer. 

Treatment. — Lay the patient on her back, with the head low. 
Supply plenty of fresh air, and give ammonia by inhalation, in a 
form not too concentrated. Spirits of camphor may be used in 
a like manner. If the attack is prolonged, a sinapism to the 



252 DISEASES AND ACCIDENTS OF PREGNANCY. 

precordia, will be found of much effect. The inhalation of amyl 
nitrite (three or four drops) is occasionally beneficial. 

If the woman is feeble, melancholy, and weeps easily, ignatia; 
if lively, gay and passionate, chamomilla; if morose and ill- 
tempered, gets little exercise, and is constipated, nux vomica; if 
the syncope is the result of exhausting disease or hemorrhage, 
china. 

Painful Breasts. — The changes which are begun early in 
pregnancy to prepare the mammae for activity, always excite 
more or less pain. The suffering sometimes becomes acute, and 
almost insupportable, especially in women who have compressed 
the breasts with corsets. 

Treatment. — If the pain is very severe, and inflammation 
seems threatened, the application of warm fomentations and 
poultices will be found useful. Bryonia suits cases of prick- 
ling and stitching pain. If there are redness, heat and indura- 
tion, belladonna is the remedy. If the glandular structure ap- 
pears to be involved in more or less inflammatory action, Phy- 
tolacca is to be given, and applied externally. 

Pain in the Side. — In the fourth or fifth month of preg- 
nancy — sometimes later — women experience severe pain under 
the false ribs, on one side, or both. Nux vomica will generally 
relieve in a few days. Bryonia, belladonna, arsenicum, and 
Pulsatilla are sometimes required. 

Pain in the Abdomen. — The excessive distension to which 
the abdomen is subjected, creates more or less pain. Inunc- 
tions of sweet oil or cosmoline will afford some relief. If the 
abdominal walls are excessively sensitive to the touch, sepia will 
often prove beneficial. 

Leucorrhcea. — Owing to the extreme vascularity and hyper- 
emia of the generative organs during pregnancy, the occurrence 
of leucorrhcea is more common than during the non-pregnant 
state. The discharge is largely from the cervical glands, but the 
vaginal glands also contribute. The secretion is sometimes very 
copious and acrid, in which case the whole genital tract and 
vulva may be hot, swollen and painful. The irritation is often 
communicated to the neck of the bladder, and produces frequent 
and painful urination. 

Treatment. — Best from sexual indulgence, and a daily enema 



ODONTALGIA. 253 

of tepid water is often all that is required. In other cases, the 
discharge persists in defiance of any sort of local treatment. 

Pulsatilla. — The discharge is thick white mucus, and is ex- 
tremely irritative. 

Hydrastis. — Irritative leucorrhcea, with co-existing indiges- 
tion and debility. (A mild solution should also be used as a 
vaginal injection.) 

Mercurius. — Yellowish, purulent leucorrhcea, producing sore- 
ness of the parts. 

Arsenicum. — Thin, burning leucorrhcea. 

Odontalgia. — Many women are tormented during pregnancy 
with toothache. This sometimes begins with almost the mo- 
ment of conception; in other cases not until a much later period. 

The most serviceable remedy for this painful affection in a 
pregnant woman, is probably sepia. If there is determination 
of blood to the head, with either redness or paleness of the face, 
belladonna. If the aching tooth is affected with caries, staphy- 
sagria and mercurius are the remedies. If the pain is very 
sudden and violent, coffea. If most violent at night, and the 
cheek is swollen, mercurius and chamomilla. When it begins 
in the evening and continues through the night, pidsatilla. If 
the pain is increased by fresh air, wine, coffee, cold, and mental 
labor, and diminished by warmth; if there is also a shooting in 
the teeth and jaws, extending into the bones of the face and 
head, with a grinding, pressing or drawing in the decayed tooth, 
nux vomica. The medicine may be tried an hour or two, but if 
relief is not then afforded, it should generally be exchanged for 
another. 

There is no doubt that pregnancy predisposes to caries, and 
the latter condition may necessitate mechanical interference, 
namely, extraction, filling, etc. "There is much unreasonable 
dread," says Playfair,* " amongst practitioners as to interfering 
with the teeth during pregnancy, and some recommend that all 
operations, even stopping, should be postponed until after de- 
livery. It seems to me certain that the suffering of severe tooth- 
ache is likely to give rise to far more severe irritation than the 
operation required for its relief, and I have frequently seen 



* " System of Midwifery," Am. Ed., 1880, p. 195. 



254 DISEASES AND ACCIDENTS OF PBEGNANCY. 

badly decayed teeth extracted during pregnancy, and with only 
a beneficial result." 

Cramps. — Pregnant women are often annoyed by cramps in 
the abdomen, feet and legs. For these, veratrum album, taken 
before going to bed, will generally suffice. Nux vomica or 
coffea may be given to nervous, sensitive women. Secale and 
cuprum are also of benefit. For cramps in the abdomen gelse- 
mium is especially well suited. 

Injuries During Pregnancy. — Injuries, which, in a non- 
pregnant state, would excite no alarm, occurring during utero- 
gestation are liable to assume threatening phases. A slight mis- 
step, a sudden jar, or a light strain, may arouse the latent uter- 
ine energies, and precipitate premature expulsion of the ovum. 
Again v a woman will suffer most serious mishaps without evi- 
dent disturbance of the even tenor of a normal pregnancy. 
Mauriceau tells of a woman in the seventh month of gestation 
who fell from the window of a house, and, besides extensive 
bruises, broke one of the bones of the forearm, and dislocated 
the wrist, without suffering miscarriage. Tyler Smith speaks 
of a woman who, in throwing some water from a window, lost 
her balance and was precipitated into the street below. Both 
thighs were broken, but she did not abort. Ovariotomy, and 
other major surgical operations, are frequently performed on 
pregnant women without loss of the product of conception. 

Treatment. — Much the same plan of treatment should be 
adopted as would be suitable to a non-pregnant woman. Best, 
for a varying length of time, must be enforced, sources of irrita- 
tion removed, fractures dressed, pain allayed, fears quieted, and 
shock overcome. For bruises, arnica will be used. If nervous 
and weak from the fright, ignaiia. If there is excited circula- 
tion, restlessness, heat and anxiety, aconite. Should there be 
throbbing carotids, injected conjunctivae, and exalted sensibility 
of sight and hearing, belladonna. If symptoms of threatened 
abortion supervene, and refuse to give way before indicated 
remedies, a full dose of morphia may be given by the mouth, or 
half the quantity may be injected into the tissues, and repeated, 
if necessary, at suitable intervals. By thus allaying mental ex- 
citement, and quieting reflex action, the emergency may be suc- 
cessfully met. Extensive separation of the ovum from its uter- 



CONSTIPATION AND DIARRHCEA. 255 

ine anchorage may have been effected, in which case the abor- 
tive process will not suffer permanent arrest. 



CHAPTEK XL 

Diseases of Pregnancy.— (Continued.) 

Constipation.— This frequently annoying complication of the 
pregnant state, is owing not so much to the pressure exerted by 
the gravid uterus, as to diminished intestinal action. The sed- 
entary life led by most pregnant women doubtless contributes 
to its production. Neglect of the bowels sometimes leads to 
fecal accumulations, occasionally of enormous size, which give 
rise to spurious labor pains, and mechanical obstruction during 
parturition. 

Treatment. — A regular habit of going to stool twice daily 
should be formed, and nothing permitted to interrupt it. Fruits 
in their season, graham bread, figs and such other articles of 
diet as have a tendency to relax the bowels, should be eaten. 
The drinking of a glass of pure cold water, or of some approved 
mineral water, in the morning on rising, together with adequate 
exercise will be found beneficial. If, in spite of treatment, and 
the observance of such habits, the bowels still remain costive, 
an occasional enema of water, soap and water, or olive oil and 
soapsuds, will afford temporary relief. 

If with the constipation there are headache, weight in the anus 
and frequent ineffectual desire, nux vomica should be given. If 
the stools are hard and dry, as if burnt, bryonia; constipation 
with excessive flatulence, lycopodium; when there is complete 
inactivity of the lower bowel, and the stools are round, hard and 
black, opium; constipation complicated with hemorrhoids, col- 
linsonia. Sepia cc has been recommended as a specific for the 
constipation of pregnant women. 

Diarrhoea. — An opposite condition of the bowels is occasionally 
met, and its neglect may lead to irritation so great as to excite 
uterine pains. Light food, in small quantities, and repose of 



256 DISEASES AND ACCIDENTS OF PREGNANCY. 

body, should be recommended. The remedies are phosphoric 
acid, Pulsatilla, ipecac, dulcamara, chamomilla, arsenicum, or 
even mercurius. 

"Vesical Irritation. — Owing to its situation, the bladder is 
peculiarly liable to functional and mechanical disturbance, ac- 
companied by a frequent desire to urinate. During the first few 
weeks, and the last two or three, this is most marked. There are 
sometimes much pain and difficulty attending micturition, when 
nux vomica will generally afford some relief. If there is invol- 
untary escape of urine, with tenesmus, camphor. In the case 
of feeble, impressible, timid women, pidsatilla. 

If the ailment becomes distressing, and remedies fail to afford 
much relief, an examination per vaginam should be made, and 
if the difficulty is found to be dependent on mechanical condi- 
tions which can be changed, careful interference should be 
practiced. In rare cases we may be driven to the use of opium 
suppositories in the vagina. 

Cough. — Besides the ordinary diseases of the respiratory 
tract, from which the pregnant woman is not exempt, she is 
sometimes troubled with a spasmodic cough, doubtless of sym- 
pathetic origin. It not unfrequently resembles whooping-cough, 
and may become so violent as to excite abortion. 

Aconite for a few days, followed by nux vomica, has proved 
efficacious. If the cough is worse in the evening, and at night, 
belladonna. If attended with vomiting, ipecac. Sepia often 
has a decided influence over it. Other indicated remedies are 
bryonia, phosphorus, and conium. 

Dyspnoea. — In some cases this arises from upward pressure of 
the gravid uterus, with consequent irritation; and in others it 
proceeds from reflex causes. 

When due to the latter, lobelia, moschus, or nux moschata are 
likely to afford relief. Nux vomica in these, and other cases, is 
often of service. If the face is flushed, and the head heavy?* 
belladonna or aconite may relieve. Arsenicum is sometimes 
efficacious. Hysterical dyspnoea will require the remedies else- 
where named. 

Sleeping with the head and shoulders elevated will be found 
to have an ameliorating effect on the distress. 

Hemorrhoids. — The pressure of the gravid uterus on the 



HEMORRHOIDS. 257 

hemorrhoidal veins., accompanied, as it often is, by a loaded 
state of the rectum, not infrequently gives rise to piles. Coin- 
cidently with this, dilatation of the rectal veins, varices in other 
parts, such as the vulva, vagina and lower extremities, are often 
observed. Distention may become so great as to produce rupt- 
ure, giving rise to vaginal or vulvar thrombus or hematocele, 
which will be described in another place. The hemorrhage re- 
sulting from such an accident is sometimes profuse. 

Treatment. — Hemorrhoids may be benefited by a regular, gen- 
tle, daily evacuation of the bowels. Much may be done to favor 
this, as observed under the head of "constipation," by having 
stated periods of going to stool. 

Therapeutics. — Belladonna. — Piles so sensitive that the wo- 
man cannot bear to have them touched ever so lightly; the back 
feels as though it would break; throbbing headache. 

Aloes. — The piles protrude, and are hot and sore, attended 
with bearing down sensations. 

Hamamelis. — Bleeding hemorrhoids, with burning, soreness, 
fullness and weight, with tendency to rawness. The local use of 
the aqueous extract is very beneficial. 

Nux vomica, — Is of greatest service to women of sedentary 
habits, and those who have been accustomed to the use of ca- 
thartics. 

Sepia. — The piles come down with even a soft stool; feeling 
of bearing and straining in the rectum ; oozing of moisture from 
the rectum; soreness between the nates. 

Sulphur. — It is suitable to piles of all descriptions, and should 
be given when any of its general characteristic symptoms are 
found. 

Collinsonia. — This is one of the best remedies. Sensation as 
of sticks, sand or gravel, in the rectum. Worse in the evening, 
better in the morning. 

^Jsculus hipp. — Blind and painful hemorrhoids, sometimes 
slightly bleeding; severe pain across the back and hips; feeling 
as of a stick in the rectum. 

Other remedies sometimes required are, aconite, apis, alum- 
ina, calcarea carb., graphites, leptandria, nitric acid, pulsatilla. 

An operation for radical cure of hemorrhoids during ges- 
tation is not advisable; but should they remain permanently 
protruded after the puerperal period has been passed, they may 



258 DISEASES AND ACCIDENTS OF PREGNANCY. 

be excised, with proper precautions, or cured by an occasional 
injection into their substance of a mixture of ergot, carbolic 
acid and glycerine. 

For the varices of the lower extremities, an elastic stocking 
may be worn. Those of the yulva may be kept in check by the 
moderate pressure of a soft pad held by a T bandage. 

Displacements of the Uterus. — The gravid uterus is liable 
to displacement, and its occurrence forms one of the serious 
complications of pregnancy. 

Anteversions and Anteflexions. — There is much to be found 
in homoeopathic literature on this subject, and one would be led 
to suppose that it is not only a common occurrence during preg- 
nancy, but that it is a frequent and serious complication of 
labor. This error proceeds from a want of clear comprehension 
of the normal inclination of the longitudinal uterine axis. The 
plane of the pelvic brim lies at an angle of about 60° with the 
horizon, and it is generally supposed that the long uterine axis 
is coincident with, or lies parallel to the axis of this plane, 
which would give the fundus uteri, as is seen in the figure, an 
inclination forward more marked than many suppose. The nor- 
mal anteversion of the impregnated uterus is, at first, sometimes 
exaggerated by the increased weight of the gravid uterine body, 
Fig. no. but the deviation is usually rec- 

tified by the gradual develop- 
ment, and upward movement, of 
the organ. In rare cases the 
deviation continues after the 
fourth month, and produces 
tenesmus of the bladder, dysu- 
ria, or incontinence. The con- 
dition, when once recognized, is 
readily overcome with, or with- 

Relative size and inclination of the . t»j * i x. a 

uterus at the close of gestation. out > an abdominal supporter. ^ A 

pessary would be of no service. 
A similar position of the uterus in late pregnancy forms what 
is known as pendulous abdomen, which is referable to inade- 
quate abdominal support, proceeding from relaxation of the 
parietes, separation of the recti muscles, or to the cicatrices left 
from operations or injuries. Curvature of the spine, and con- 




RETROFLEXION. 



259 



tracted pelvis, favor its production. Cases are on record wherein 
the recti muscles were separated, and the uterus was anteverted 
between them, covered only by fascia and integument, nearly to 
the knees. 

Treatment clearly consists in the reduction of the displace- 
ment, and the application of a firm abdominal bandage. 

Retroversion. — This is now regarded as a comparatively in- 
frequent form of uterine displacement during pregnancy, and 
when spontaneous rectification does not occur, the development 
of the organ forces it into a flexed condition. 

Retroflexion. — This is an uncommon occurrence in women 
for the first time pregnant. It may arise during pregnancy 

Fig. 111. 




Retroflexion of the gravid uterus. 

from the same causes which produce it in the non-pregnant 
state, such as a fall, or undue distension of the bladder and rec- 
tum; but sometimes it is doubtless due to displacement of the 
organ which antedates conception. 

With the advance of pregnancy the uterus generally straight- 
ens and clears the pelvic brim, without serious inconvenience. 
This spontaneous rectification is not so apt to occur in chronic 
cases, as in recent ones, because tissue tonicity is greatly im- 



260 DISEASES AND ACCIDENTS OE PEEGNANCY. 

paired. In many cases the fundus does not ascend above the 
sacral promontory at the usual time, but remains incarcerated 
in the pelvic cavity, when the condition which was, perhaps, at 
first, one of retroversion, now becomes partial retroflexion, by 
means of which the uterine cavity is divided into diverticuli or 
pouches — an anterior and a posterior. 

The symptoms of incarceration embrace dysuria, or even com- 
plete retention, vesical tenesmus, incontinence of urine, painful 
defecation, constipation or obstipation, severe sacral snd lum- 
bar pains extending into the thighs. In grave cases, emesis, 
and all the other symptoms of ileus, may be developed. At any 
time during incarceration, abortion may occur, followed by re- 
lief of the threatening symptoms ; but should it persist, metritis, 
parametritis and peritonitis may ensue with fatal result. Death 
may also result from pathological processes set up in the blad- 
der by retention and decomposition of urine. These are cysti- 
tis and gangrene, which, in turn, give rise to septicaemia or vesi- 
cal rupture. The retention may lead to uraemic poisoning, and 
thus to death. 

The diagnosis of retroflexion and incarceration of the uterus 
is not often difficult. As the physician passes his ringer along 
the vagina, in order to reach the os uteri, he will find that it 
impinges upon an elastic swelling along its posterior and supe- 
rior border, lessening and changing the course of the latter, and 
if pregnancy be advanced to the fourth or fifth month, com- 
pletely filling the cavity of the lower, or true pelvis. The cervix 
uteri, if discovered, will be found behind or above the posterior or 
inner face of the symphysis pubis. On abdominal examination, 
the fundus uteri cannot be felt above the pelvic brim. By bi-man- 
ual examination, the alternate relaxation and contraction of the 
gravid uterus can be made out, and differentiation thus made 
between the body and fundus of the uterus, and a swelling of a 
different kind in the same situation. The clinical history of the 
case will also give important data. 

The distinction between an incarcerated uterus and an extra- 
uterine pregnancy is sometimes difficult, necessitating a thor- 
ough and careful bi-manual examination, aided, in cases of ab- 
dominal tenderness, by the employment of an anaesthetic. 

Treatment. — In these trying cases delay is dangerous, owing 
to the progressive increase in size of the uterus, and the per- 




RETROFLEXION OF THE UTERUS. 261 

nicious effects of long-continued pain and physical disturbance. 
The object to be held in view, is a return of the fundus uteri to 
a situation above the pelvic brim. But before attempting the 
operation there are certain preliminaries to be observed, the 
first of which is thorough evacuation of the bladder and rectum. 
For the purpose of drawing the urine there is no instrument 
superior to the soft rubber catheter, of small size, as the ure- 

Fig. 112. 




Soft Rubber Catheter. 

thra is too greatly altered in its course and calibre by the com- 
pression to which it is subject, to admit of the safe use of a stiff 
catheter. Even with this instrument we may sometimes utterly 
fail, in which case puncture of the bladder, if distension exists, 
may be practiced above the symphysis pubis by means of a 
small needle of the aspirator. 

Another preliminary to the operation in cases of real uterine 
incarceration is the induction of anaesthesia, and the placing of 
the woman in the Sims' latero-prone position. The knee-chest 
position should be prescribed if no ansesthetic is used. The 
operation itself is performed by introducing four ringers into 
the rectum, and pushing upward on the fundus uteri. Dr. 
Barnes * recommends turning the fundus to one side, so as to 
avoid the sacral promontory. Bepeated efforts may have to be 
made to acquire complete success. Mere evacuation of the blad- 
der and rectum, and the influence of gravity brought to bear 
through the assumption of the knee-elbow, or knee-chest posi- 
tion, may be adequate in some cases to bring about complete 

*" Obstetric Operations," Third Am. Ed., p. 276. 



262 DISEASES AND ACCIDENTS OF PREGNANCY. 

reduction. This result may be still further promoted by retrac- 
tion of the perineum with the fingers, or by Sims' speculum, 
and the admission of air into the vagina. 

An instrument has been devised by Dr. H. N. Guernsey, 
which serves an admirable purpose in the accomplishment of 
difficult reduction. It consists of a curved rod of steel, upon the 
end of which is a hard smooth ball, about three-fourths of an 
inch in diameter. The instrument is provided with a suitable 
handle. " As soon as a case of this form of displacement is 
clearly diagnosed," says the Doetor, * "if the urine or feces 
are retained, the usual means should be at once adopted for 
their evacuation. The patient should then be placed on the 
bed, near its edge, upon her knees and elbows, so that the force 
of gravity may assist in the reduction. The ball of the instru- 
ment, well lubricated, is to be brought to the anus, with the con- 
vex surface of the rod upwards, then gently pressed till within 
the sphincter, when the handle should be slightly elevated, so 
as to bring the ball against the anterior wall of the rectum. 
The instrument is now to be firmly and carefully pressed up the 
rectum, wh<m the ball will elevate the fundus, care being taken 
to raise the handle of the instrument more and more as progress 
up the rectum is made; and presently the uterus will regain its 
normal position immediately posterior to the symphysis pubis." 

After reduction of the dislocation, it has been recommended 
that a Hodge pessary of large size be introduced into the vagina, 
and allowed to remain until the uterus has reached a size which 
precludes the possibilty of a return to its former position. 
Others advise simple lateral decubitus, without the use of any 
pessary. The after treatment includes also careful attention to 
the bladder and rectum, neither of which should be permitted 
to become loaded. 

It occasionally happens that replacement of the uterus is pre- 
vented by inflammatory adhesions, or by the secondary swelling 
of the displaced organ, in which case the induction of abortion 
is the only recourse. Mechanical obstacles to the ordinary 
methods of arousing uterine action are here met, and the accom- 
plishment of the object in a tolerably safe manner will tax one's 
ingenuity and skill. The introduction of a uterine sound, or a 

* " Guernsey's Obstetrics," p. 116. 



PROLAPSE OF THE UTERUS. 263 

flexible catheter is rarely practicable. Dr. P. Mtiller,* in a case 
of complete retroversion, resorted to the following ingenious 
expedient, a knowledge of which may be of benefit to others : 
He cut off the end of a male silver catheter, and after having 
bent the extremity, he hooked it within the cervix uteri which 
was looking upwards and f owards. Through this artificial chan- 
nel he passed a piece of cat-gut, and left it between the mem- 
branes and uterine wall. In twelve hours the foetus was ex- 
pelled. If our efforts to pass a foreign, but innocuous, substance, 
within the uterus, prove unavailing, the organ may be punctured 
through the vagina with an aspirator needle, or a fine trocar, and 
a portion of the liquor amnii withdrawn, without much risk to 
ihe woman, if practiced under strict antiseptic precautions. 
This is a sure method of bringing on abortion. 

Prolapse of the Uterus. — We have already directed atten- 
tion to the normal descent of the gravid uterus during the early 
weeks of gestation; but in some cases physiological bounds are 
passed, and decided prolapsus, and even procidentia may be 
produced. f Abnormal downward displacement of the organ 
produced during pregnancy is generally the result of mechani- 
cal violence, and its result is often abortion, brought about di- 
rectly by uterine congestion and hemorrhage. It is most fre- 
quent in multipara, and, in a certain proportion of cases, the 
prolapsus antedates the pregnancy in which it is observed. 

The disturbances to which this sort of displacement gives rise, 
vary in severity and character with the stage of pregnancy at 
which it occurs. Should the condition remain unrectified, the 
bladder and rectum become irritated, there is a feeling of weight 
in the anus, and painful tractions in the groins, lumbar regions, 
and umbilicus. A foetid discharge is set up; no change of posi- 
tion relieves the suffering, and a state of marasmus is liable to 
supervene. These symptoms become intensified, until, gener- 
ally, sufficient irritation is created to bring on abortion. 

Procidentia uteri is simulated by hypertrophy of either the 
supra, or intra-vaginal portion of the cervix. Excessive devel- 

* " Zur Therapie der Retroversio Uteri gravidi." " Beitr. Ziir Geburtsh." 
Bd. iii., p. 67. 

fVimmer (vide Cazeaux), reported a ease of complete procidentia of the 
gravid uterus, the entire organ lying between the thighs. 



264 DISEASES AND ACCIDENTS OF PREGNANCY. 

opment of the intra-vaginal portion of the cervix is sometimes 
transformed into a pulpy-like mass, and, as a consequence of 
constant friction, abortion is brought on. This hypertrophied 
condition of the enlarged cervix appears to exercise a prejudi- 
cial effect on utero-gestation and parturition, and amputation of 
the part is sometimes resorted to, during the third month, with- 
out interrupting the course of pregnancy. 

Prolapsus is generally spontaneously rectified as pregnancy 
advances, but in some caess it becomes necessary to gently, but 
firmly, manipulate the organ, and restore it to a normal situa- 
tion. After such reduction, perfect rest in bed should, for a 
time, be enjoined. The vesical distention which is liable to 
complicate the anomaly, should be relieved, if necessary, by the 
use of the catheter. Resort to this instrument may often be 
avoided by the woman assuming the dorsal decubitus, with ele- 
vated hips, for the act of urination. 

Where there is actual incarceration, scarification should be 
performed, and reposition attempted. If reduction cannot be 
accomplished, abortion should be induced before compression 
of the pelvic tissues has become excessive, or has been long 
continued. 

Hernias of the Pregnant Uterus. — These are true eventra- 
tions, resulting from extreme relaxation of the abdominal walls, 
and may very properly be classified with what has been de- 
scribed as anteversion of the gravid uterus. The anomaly is 
fortunately a rare one. The most frequent forms are the um- 
bilical and the ventral. Femoral and inguinal uterine hernias, 
while exceedingly rare, and hernias through the foramen ovale, 
and the great sacro-sciatic foramen, have been known to occur. 
Ventral hernias often form, from separation of the recti muscles, 
and occasionally from the yielding of extensive cicatrices result- 
ing from abdominal incisions. 

Certain of these forms are many times congenital, such as the 
femoral and inguinal, and those through the foramen ovale and 
greater sacro-sciatic foramen. The latter two, however, should 
not here be considered, as pregnancy was never known to occur 
in a uterus which had escaped through one of these openings. 

Diagnosis is not often attended with much difficulty, when due 
attention is given to the form and development of the hernial 
tumor, and the absence of the uterus from its usual place in 



SUKGICAL OPEBATIONS DURING PREGNANCY. 265 

the pelvis, together with vaginal traction toward the displaced 
organ. 

In the way of treatment of these vexing anomalies, reposition 
occupies the most prominent place. It is rarely practicable, 
however, unless the condition is discovered in its incipiency, 
though in a case related by Ruysch, a midwife, by raising the 
tumor, succeeded in returning the foetus into the abdomen, after 
expulsive efforts had begun, and the delivery was effected as 
usual. 

Pregnancy occurring in inguinal and femoral uterine hernias 
always terminates in abortion or premature labor. When repo- 
sition, attempted in the usual manner, fails, it may sometimes 
still be accomplished by dividing the hernial ring. This would 
scarcely be a justifiable procedure, except in cases well advanced. 
Eeduction by the ordinary measures failing in an early stage, 
abortion should be induced, and thus the dangers attendant upon 
further development, and ultimate expulsion, averted. 

In every instance, after successful reduction of the disloca- 
tion, its return should be prevented by a well-adjusted truss. 

Surgical Operations During Pregnancy.— Massot* con- 
cludes, from the observation of a considerable number of cases, 
that ordinary surgical operations do not interfere with pregnancy 
unless they materially and permanently disturb the uterine cir- 
culation, or call into activity the uterine muscular force by reflex 
irritation. This will most frequently be the result of operations 
upon the external or internal genital organs. Cohnstein f states, 
as the result of his researches, that after operations and injuries, 
pregnancy reaches a normal termination in 54.5 per cent, of all 
cases. Interruption of pregnancy was, in his cases, determined: 
(a) by the period of pregnancy when the operation took place, 
occurring more frequently as the result of surgical measures 
resorted to in the third, fourth, and eighth months; (6) upon 
the seat of the operation, resulting in two-thirds of all cases, 
from operations upon the genito-urinary organs; (c) upon the 
extent of the wound, following amputations, exarticulations, and 
ovariotomies with great relative frequency; (d) upon the nuin- 

* " Ueber d. Einfluss traumat. Einwirk. aufd. Verlaufder Schwangerckefb." 
Schmidt's " Jakrb.,'' 1874, 164 p. 266. 

f " Ueber ckirurg. Op. bei. Sckwangeren." Volkmann's " Samml. Klin. Voitr." 
No. 59, 1873, p. 493. 



266 DISEASES AND ACCIDENTS OE PKEGNANCY. 

ber of children, occurring in multiple pregnancy with uniform 
regularity. Age seemed to exert no causative influence. Abor- 
tion directly results, under these circumstances, from reflex 
irritation, or from foetal death, referable to hemorrhage, or to 
septic poisoning on the mother's part. The prognosis, so far as 
the woman is concerned, depends upon the time when delivery 
occurs. The mortality ordinarily attending delivery, if at term, 
is insignificant; for abortions and premature deliveries it amounts, 
according to Cohnstein, to thirty-three per cent. The most 
frequent causes of the mother's death are shock, peritonitis, 
septicaemia, hemorrhage, and oedema pulmonalis. In view of 
the manifest danger from operations of any magnitude, it may 
be stated as a general law, that surgical measures not absolutely 
indicated by the existence of pathological conditions, liable to 
aggravations by delayed interference, should be postponed until 
after confinement. Those morbid conditions, however, whose 
development is hastened by pregnancy, or whose existence offers 
mechanical obstacles to parturition, must be early subjected to 
operative interference. This remark applies with special force 
to carcinomatous growths in any part of the body, and to intra- 
pelvic tumors. 

The time of operation should not coincide with the time of 
the suspended menstrual epoch, as abortion is more likely to 
occur at that period.* For a similar reason it is recommended 
that the third, fourth and eighth months should be avoided. 
Massot is of the opinion t that anaesthetics, when employed 
during operations on pregnant women, exert rather a favorable, 
than a prejudicial, effect upon foetal life, by diminishing reflex 
irritation. J 

Cardiac Diseases. — These affections vary in seriousness with 
their form. Myocarditis interferes with the development of car- 
diac hypertrophy, compensatory for existing valvular lesions. 
Endocarditis in pregnancy shows a strong tendency to assume 
the fatal ulcerative form, while pericarditis has no marked effect 
upon the normal course of utero-gestatioii. The chief element 
of danger in these cases is the necessity which exists for hyper^ 
trophy of the organ to compensate the increased arterial pres- 

*Spiegelbekg, "Lehrb. d. Teburtsh.," p. 268. 

f Massot, loc. cit., p. 267. 

X Vide. Lusk's Midwifery, p. 263. 



ERUPTIVE FEYEES. 267 

sure. Another important element of danger is the varied and 
perturbed heart-action found during labor, under the suddenly 
changing conditions of pressure produced by the alternating 
uterine contractions and relaxations. 

Out of twenty-eight cases of cardiac disease during pregnancy, 
collected by Dr. Angus MacDonald,* sixty per cent, proved fatal. 

The symptoms of serious cardiac lesions do not generally appear 
until after the middle of pregnancy, and gestation rarely advances 
to term. The symptoms, when severe, usually show themselves 
in the form of pulmonary congestion, pulmonary oedema, with 
occasional pneumonia and pleurisy. The most serious valvular 
lesions seems to be here, as in non-pregnant conditions, 1. Mi- 
tral stenosis, and 2. Aortic insufficiency. After pregnancy ter- 
minates, and the terrible strain of parturition is safely passed, 
the symptoms usually disappear, though when the case has 
developed threatening pathological conditions before labor, the 
woman is liable to sink during puerperality. Foetal nutrition is 
apt to become impaired to a marked degree, resulting in imper- 
fect development, and death soon after birth. 

"Women who are the subjects of cardiac disease of any degree 
of gravity, should be encouraged to remain single. The treat- 
ment of the cardiac lesion will not be materially modified by the 
existence of pregnancy. The symptoms must be carefully stud- 
ied, and the similimum chosen. Sanitary regulations are of the 
highest importance. The patient should have plenty of fresh 
air and nourishing food, though great precaution should be ob- 
served not to overload the stomach. Exposure to cold, and all 
forms of over exertion must be avoided. Ansesthetics may be 
employed during labor, — preferably chloroform — but with un- 
usual caution. 

Eruptive Fevers. — The pregnant woman is not exempt from 
liability to such contagion. Measles is not infrequent, and it 
assumes serious features in quite a percentage of cases. It 
seems to manifest a tendency to become hemorrhagic and to 
produce metrorrhagia, terminating fatally to mother and child. 
Pneumonia is a very frequent and dangerous complication of 
the disease in pregnancy. Abortion is not an uncommon result 
of the disorder. 

* "Obstet. Jour. » 1877. 



268 DISEASES AND ACCIDENTS OF PREGNANCY. 

Yariola, of the eruptive fevers, is most frequently met, and is 
withal, the most disastrous in its results. It attacks from pref- 
erence women who are in the early stages of pregnancy, but its 
onset later in gestation is attended with greater danger, con- 
stantly augmented as it nears parturition. The dangerous as- 
pects of the case are found in the tendency to metrorrhagia and 
abortion which is usually manifested. The severe and confluent 
forms of the disease are almost certainly fatal to both mother 
and child. When variola is of a mild form, and especially when 
modified by recent vaccination, its course is generally favorable, 
though abortion often ensues. 

Scarlatina. — A striking peculiarity of this disease is that its 
contagion does not always excite immediate diseased action in 
the pregnant woman, but occasionally its force appears to be 
felt only after the lapse of a considerable time. For example, a 
woman, even in the earlier months of pregnancy, may be ex- 
posed to the disease, but temporarily escape its baneful influ- 
ences only to fall a prey to it in the puerperal state. Olshausen,* 
after thorough search, was able to collect only seven cases of 
scarlatina in pregnant women, while he found one hundred and 
thirty-four in puerperse. 

The mortality from the disease occurring in pregnant women, 
is high. This disorder does not appear to be materially altered in 
its general characters by the existing pregnancy, and its usual 
treatment requires no important additions. 

Continued Fevers. — {Typhus, Typhoid, and Relapsing Fe- 
vers.) Pregnant women are liable to attacks of any of the 
continued fevers, which do not appear to be aggravated by the 
pregnant condition, but, when severe, are apt to provoke abor- 
tion. Out of seventy-two cases of typhoid, sixteen aborted; and 
out of sixty- three cases of relapsing fever, pregnancy was inter- 
rupted in twenty-three. 

These forms of fever are more likely to attack women in the 
earlier months of pregnancy, and their effects vary with the 
form of fever present. Typhoid fever is frequently, and relaps- 
ing fever almost uniformly, accompanied by abortion, or prema- 
ture labor consequent on profuse uterine hemorrhages. Accord- 

* Olshausen. " Untersuch. iib. d. Complie. des Puerp. m. Scarlat. u. d. 
sogenannte S. puerperalis." " Arch. f. G-ynaek.," ix, 1876, p. 169 ; BBAXTON 
Hicks. " Trans, of the Obstet, Soc. London," vol. xvii. 



PNEUMONIA. 269 

ing to Schweden, one of the chief sources of danger to the 
fcetus in such conditions, is the hyperpyrexia. 

The treatment of these cases is not essentially altered by the 
coexisting pregnancy. 

Malarial Fever. — This complication of pregnancy is not often 
observed. When the poison lurks in the system from former 
infection, it is often lighted up during recurring pregnancies. 
This form of fever does not often result in abortion, even though 
persistent in its stay. The occurrence of labor interrupts the 
paroxysms for a time, but, in the second or third week of the 
puerperal state, they are apt to return. The paroxysms manifest 
either an anticipating, or a retarding tendency, being very irreg- 
ular in their appearance. The fever sometimes takes on a per- 
nicious type, and requires energetic treatment. It has been 
suggested by Dr. Fordyce Barker, — and the suggestion is a for- 
cible one, — that, in the administration of remedies, regard must 
be had to the impaired powers of digestion and assimilation. 

Pneumonia. — Of all the acute inflammations of the envelopes, 
or of the parenchyma, of the organs, pneumonia is one of the 
most likely to produce abortion or premature labor.* Grisollef 
reported four cases of his own, and collected eleven others. Of 
these fifteen women, ten had not reached the sixth month, and 
four aborted a few days after the onset of the disease. Only 
one, whose pneumonia was limited, ^recovered without serious 
symptoms. 

It seems clear from these data that pneumonia, occurring in 
pregnancy, is a remarkably fatal disease. The same facts, how- 
ever, establish the comparative infrequency of the complication. 
The strong tendency to abortion is probably attributable to the 
importance of the organ directly involved, the gravity of the 
disease, the hyperpyrexia, the intensity of the general reaction, 
and the numerous sympathetic disorders which it produces in 
all the functions, much rather than to the paroxysms of cough- 
ing. The cause of the maternal mortality is not altogether clear, 
but it is probably referable to the coexisting hydremia, and to 
the inability of the poorly nourished heart to restore the bal- 
ance of pulmonary circulation disturbed by the consolidation of 

* Cazeaux. " Theoret. and Pract. Midwifery," Am. Translation, p. 448. 
f Arch. Gen de Me*d. vol, xiii, p. 298. 



270 DISEASES AND ACCIDENTS OF PEEGNANCY. 

lung-tissue, and by the consequent impermeability of large cap- 
illary areas.* (Edema of the lungs, resulting from weakened 
heart action, is the immediate cause of death. The occurrence 
of abortion or premature labor during the disease, greatly aug- 
ments the dangers, and we should recollect this if the question 
of the induction of premature evacuation of the uterus is sug- 
gested. If labor has already begun, every reasonable effort 
should be made to accelerate delivery. 

Under judicious homoeopathic management we look for better 
results than have been obtained from other forms of treatment. 
The remedies should be adapted more especially to the pul- 
monary condition, and are those most commonly employed in 
treating the disease when not associated with pregnancy. 

Phthisis. — Contrary to the generally accepted belief, preg- 
nancy, in the majority of cases, hastens the progress of phthisis, 
and precipitates its development. The latter is true, of course, 
chiefly in those women who have an hereditary, or a strongly-ac- 
quired, tendency to the disease. Out of twenty-seven cases of phthi- 
sis collected by Grisolle,f twenty-four showed the first symptoms 
of the disease during gestation; from which facts we are led to 
conclude that pregnancy does not exert a protective influence 
against the development of this disease. Women in the advanced 
stages of phthisis are not susceptible to impregnation. Spiegel- 
berg X says that women with inherited tendencies to the disease, 
often escape it during their first pregnancy, only to fall under 
its baneful influences in a subsequent one. When such women 
pass through pregnancy and parturition in safety, their vital 
forces are extremely reduced, and they have little or no milk for 
their children, who are nearly always feeble, poorly nourished, 
and inherit consumptive tendencies. . 

It is fortunate for such .women that they have little milk, as 
they are thereby obliged to resort to other sources of nutritious 
supplies for their offspring, and thereby economize their remain- 
ing forces. Girls possessing tendencies to phthisis should be 
dissuaded from entering the married state, as their interests, and 
those of society, will be best subserved by their never becoming 
mothers. 

*Lttsk. '• Science and Art of Midwifery," p. 258. 

f'Obstet. Journal," 1877. 

+ "Lehrb. d. Geburtsh.," P- 226, 



SYPHILIS IN PKEGNANCY. 271 

Syphilis. — Primary syphilis seems to luxuriate in pregnant 
women. The period of incubation is not limited to two weeks, 
but may be six weeks, or even longer. The lesions are more ex- 
tensive than in the non-pregnant, and may involve the vagina, 
cervix, labia, nates, and thighs, and consist of swelling, redness, 
excoriation, and ulceration of the mucous membrane and skin, 
oedema, eczema, follicular abscesses, and even necrosis of con- 
nective tissue. The secondary symptoms are unusually mild, 
consisting, in the main, of glandular induration, papules in va- 
rious parts, but especially about the genitals, and psoriasis of 
the palms and soles. 

The ravages of syphilis are experienced more particularly by 
the foetus. If either parent, at the time of fertile intercourse, 
is suffering from general syphilis, the poison is communicated 
to the product of conception. The infection thus transmitted 
to the foetus is not often communicated by the foetus to the 
mother. Furthermore, the woman who contracts the disease 
subsequently to impregnation, i. e., while carrying the foetus, 
cannot infect the latter. In other words, tainted spermatozoa 
may infect the ovum, without the woman at any time becoming 
infected, and an ovum which was free from taint at time of im- 
pregnation will not become infected by subsequent maternal 
contraction of the disease, for the syphilitic poison will not 
traverse the septa between the foetal and maternal vascular sys- 
tems. If both parents are the victims of general syphilis at the 
time of impregnation each communicates the poison to the off- 
spring.* Exceptions to the foregoing rules are rare. 

It must not be inferred, however, that every child born of 
infected parents will present evidences of the disease in ques- 
tion. Indeed, it seems probable that such is not the most fre- 
quent result. f Legendre, in discussing the question of the 
latent condition of syphilis in the parents, and of its influence 
upon the child, says that out of 63 patients who came under his 
observation, there were 14 who had 68 children during the in- 
terval between primary and secondary stages. Of this number, 
35 died without ever manifesting any signs of infection. The 
average age of the children at the time of death was seven 

* Kassowitz. " Die Verenbung d. Syphilis," Strieker's " Med. Jahrb," 
p. 372. 

t Cazeaux. " Theoret. and Pract. Midwifery," p. 542. 



272 DISEASES AND ACCIDENTS OF PBEGNANCY. 

years. All the surviving children (33) enjoyed good health, the 
mean of their ages being seventeen years. 

The conditions under which it proves transmissible, varies con- 
siderably. When the disease is allowed to proceed, unmodified 
by treatment, the poison may never be wholly eradicated; but 
the liability of transmitting it to the offspring seems to be lost 
after an average period of ten years. Because the disease is 
latent, it must not be inferred that there is no danger of infect- 
ing the offspring, though it is admitted that such a condition 
diminishes the probability of communicating the infection. The 
foetus may perish in utero, or it may be born alive only to die 
early. The disease does not always declare its existence under 
two years from date of birth. Children begotten during the 
first two or three years after infection of either parent, are al- 
most sure to be expelled prematurely. 

Women who at the time of pregnancy, or within a year or two 
previously, have suffered from syphilis, will be less liable to en- 
tail the disease on their offspring, if given mercurius for a time, 
at intervals during pregnancy. In old-school practice, mercu- 
rial inunctions are regarded as most beneficial. When the dis- 
ease is contracted during pregnancy, and there are primary or 
secondary sores about the genitals, care should be exercised to 
protect the foetus from infection during delivery. 



PART III. 

LABOR. 
CHAPTEE I. 

We have traced the growth and development of the foetus to 
maturity, have considered the diseases and accidents to which it 
is liable, the phenomena and management of its premature ex- 
pulsion, and we now come to that part of our subject that treats 
of its expulsion at the close of mature utero-gestation, which 
period, in the human female, is completed in about ten lunar 
months from the date of impregnation. 

Causes of Labor. — The following observations by Lusk on 
this subject are so clearly and learnedly set forth, that they are 
here transcribed almost verbatim et literatim* Speculation as 
to the proximate causes of labor have so far proved profitless. 
The following particulars comprise the extent of our knowledge 
of the conditions which prepare the way during pregnancy for 
the final expulsive efforts: 

1. During the first three months, the growth of the uterus is 
more rapid than that of the ovum, which is freely movable 
within the uterine cavity, except at its placental attachment. In 
the fourth month the reflexa becomes so far adherent to the 
chorion that it can only be separated by the exertion of some 
slight degree of force, and the amnion is in contact with the 
chorion. After the fourth month, the chorion and amnion are 
agglutinated together, though even at the termination of preg- 
nancy the one may with care be separated from the other. Af- 
ter the fifth month, the agglutination of the decidua vera and 
reflexa takes place. In the second half of pregnancy, the rapid 
development of the ovum causes a corresponding expansion of 

* Lusk. " Science and Art of Midwifery," p. 123. 

273 



274 LABOR. 

the uterine cavity, the uterine walls becoming thinned, so that, 
by the end of gestation, they do not exceed, upon the average, 
two or three lines in thickness. The vast extension of the uter- 
ine surface is not, however, simply a consequence of over- 
stretching, a fact shown by the circumstance that the uterus, to- 
ward the close of gestation, is increased nearly twenty-fold in 
weight, and by the histories of extra-uterine fcefcations, in which, 
up to a certain limit, the uterus enlarges progressively, in spite 
of the non-presence of the ovum. The augmented weight of the 
uterus is the result of the increase in length and width of the 
individual muscular fibre-cells, the extreme vascular develop- 
ment, and the abundant formation of connective tissue. Up to 
the sixth and a half month there has further been observed a 
genesis of new fibre-cells, especially upon the inner uterine sur- 
face. According to Kanvier, the smooth muscular fibres become 
striated as the end of gestation is reached.* 

The precise manner in which the distention of the uterus is 
accomplished has as yet not been demonstrated. A priori only 
two possibilities are apparently admissible, viz: either the indi- 
vidual structure elements are stretched after the manner of elas- 
tic bands, or a rearrangement of the muscular elements takes 
place in such wise that a certain proportion of the fibre-cells, in- 
stead of lying, as in the beginning of pregnancy, parallel to one 
another, gradually, with the advance of gestation, are displaced, 
so that the ends -only are in juxtaposition. It is probable, 
though not proved, that toward the close the thinning of the 
wall is the result of both conditions. Bearing in mind these 
premises, it becomes a disputed question as to whether one of 
the causes of labor is not to be found in the reaction of the 
uterus, as a hollow, muscular organ, from the extreme tension to 
which its fibres are ultimately subjected. Countenance to the 
affirmative side is afforded by the tendency to premature labor 
in hydramnios and multiple pregnancies, in which a high de- 
gree of tension is reached at a period considerably in advance of 
the complete development of the foetus. 

2. There is a perceptible increase of irritability in the uterus 
from the very beginning of gestation. Indeed, the facility with 
which contractions may be produced by manipulating the organ 

* Vide Taenier et Chantreuil. " Traite de l'Art des Accouchments," 
p. 203. 



THE CAUSES OF LABOE. 275 

through the abdominal walls, has been put forward by Braxton 
Hicks as one of the distinguishing signs of pregnancy. This ir- 
ritability is especially marked at the recurrence of the menstrual 
epochs, and becomes a more and more prominent feature in the 
latter months, when spontaneous painless contractions are ordi- 
nary incidents of the normal condition. 

3. The researches of Friedlander, Kundrat, Engelmann, and 
Leopold, have demonstrated that the decidua vera of pregnancy 
is distinguishable into an outer, dense, membranous stratum, 
composed of large cells resembling pavement epithelia, probably 
metamorphosed cylindrical cells, and what appears to be a sub- 
jacent mesh-work, formed from the walls of the enlarged decid- 
ual glands. It is in this spongy layer that the separation of the 
decidua takes place, the fundi of the glands persisting, even af- 

FlG.113. 




The Uterine Mucous Membrane. A. Amnion. R. Reflexa. D. Decidua 
Vera. D. B. Glandular Spaces of the Lower Stratum. M. Muscular 
Structure.— Engelmann. 

t 
ter the expulsion of the ovum. By many, a fatty degeneration 
of the cells of the decidua has been observed toward the end of 
pregnancy; but Leopold, Dohrn, and Langhans have shown that 
this is not of constant occurrence.* The trabecule which in- 
close the spaces of the net-work, diminish in .size with the ad- 
vance of pregnancy. Thus, while they measure at the fourth 
month about 1-500 of an inch in thickness, they become gradu- 
ally reduced in the subsequent months to 1-2500 of an inch, a 

♦Leopold. "Studien iiberde de Sehleimhaut," etc., "Arch. f. Gynaek." 
Bd. xi., p. 49. 



276 LABOR. 

change which materially facilitates the peeling off of the decid- 
ual surface. * 

4 From the fifth month onward, cells of large size make their 
appearance in the serotina, especially in the neighborhood of 
thin-walled vessels. The largest of these so-called giant-cells 
contain sometimes as many as forty nuclei. Though a physiolog- 
ical product, they resemble for the most part the so-called spe- 
cific cancer-cells of the older writers. They are of special obstet- 
ric interest, from the fact observed by Friedlander, and confirmed 
by Leopold,f that they penetrate the uterine sinuses from the 
eighth month, and lead to coagulation of the blood, and to the 
formation of young connective tissue, by means of which a por- 
tion of the venous sinuses becomes obliterated before labor be- 
gins. The subtraction of these vessels from the circulation tends 
to increase the amount of venous blood in the intervillous 
spaces of the placenta. 

5. It is proper to recall here the fact that the nerve-filaments 
of the uterus are derived in principal measure from the sympa- 
thetic system. The large cervical ganglion, which in pregnancy 
measures about two inches in length, by one and a half inches in 
breadth, receives, however, in addition to the sympathetic fibers, 
filaments from the second, third and fourth sacral nerves. 

Physiology has as yet left unsettled the question as to the 
main channels of the motor impulses which are conveyed to the 
uterus during labor. One of Lusk's hospital patients, with 
paralysis of the lower extremities, retention of urine, and loss of 
power over the sphincter-ani muscle, had a perfectly natural, 
though painless delivery. The cause of the paralysis was obscure, 
the patient subsequently making a complete recovery. Jacque- 
martj reports a similar case, in which the paralysis was due to 
partial compression of the cord at the level of the first dorsal 
vertebra. On the other hand, Schlesinger§ has shown that the 
sympathetic is not the only motor nerve, as reflex movements of 
the uterus follow stimulation of the organ when all the branches 
of the aortic plexus have been carefully divided. 

* Engelmann. " The Mucous Membrane of the Uterus," p. 45. 

f Op. cit, p. 492, et seq. 

JTarnter et Chantreuil, " Traite* de l'Art des Accouchments," p. 229. 

|Ober und Schlesinger, Strieker's " Wiener med. Jahrbuch," 1872. 



THE CAUSES OF LABOE. 277 

A motor centre for uterine contractions has been proved to 
exist in the medulla oblongata. This centre is excited directly 
to action by anaemic conditions, and by the presence of carbonic 
acid in the blood conveyed to it. Yivid mental emotions may 
either awaken or suspend uterine contractility. 

Reflex movements of the uterus may be provoked by stimulat- 
ing the central end of any of the spinal nerves, a fact which 
serves to explain the consensus long recognized as existing 
between the breasts and the generative organs. When the spi- 
nal cord is divided below the medulla oblongata, this phenome- 
non is no longer observed. Direct stimuli to the uterus, how- 
ever, determine contractions independently of the medulla oblon- 
gata, the spinal cord then acting as a reflex centre. The pres- 
ence of asphyxiated blood in the arterial trunks acts as a physio- 
logical stimulus to labor.* By the separation of the decidua 
from its organic connection with the uterus, the ovum acts as a 
foreign body, and, as is well known, speedily awakens uterine 
movements. Finally, it has been shown by Kehnerf that, when 
a cornu is removed from the uterus during labor, rhythmic con- 
tractions of the muscular fibres will continue from a half -hour to. 
an hour after separation, provided only the tissues be kept moist 
and at a suitable temperature. 

The following theory of the causes of labor is offered, not because 
of its completeness, but merely as a means of grouping the fore- 
going facts together in the order of their relative importance. 
The advance of pregnancy is associated with increase in the irri- 
tability of the uterus, a property most pronounced at, the recur- 
rence of the menstrual epochs. By thinning of the partitions 
between the glandular structures the way is prepared, as the 
time for labor approaches, for the easy separation of the dense 
inner stratum of the decidua. The ready response of the uterus 
to stimuli reflected from the peripheral extremities of the spinal 
nerves, to direct local irritation, and to the presence of blood 
surcharged with carbonic acid in the uterine vessels, explains 
the frequency of painless contractions for days, or even weeks, 
in some cases, previous to labor. To these means of exciting 
uterine motility, there should be added, in all probability, the 

*Vide SCHLESINGEE, Strieker's " Wiener med. Jahrbuch," 1873. 

fBeitrage zur vergleichende und experimentellen Geburtskunde," 2tes Heft. 
p. 48. 



278 LABOE. 

reaction of the uterine muscle, from the tension to which it is 
subjected by the growth of the ovum, and to circulatory disturb- 
ances in the cerebral centres sometimes affected by vivid emo- 
tions. Frequently repeated uterine contractions, without partial 
separation of the decidua, are hardly comprehensible after the 
decidua vera and reflexa are brought into close contact with one 
another. Such a physiological separation would, of necessity, 
when of sufficient extent, by converting the ovum into a foreign 
body, furnish an active cause for the advent of labor, in the same 
way that labor is prematurely excited by a similar separation 
when artificially induced. Thus, by the time the development 
of the foetus is completed, all things are in train for its expulsion. 
When other causes do not early operate as determining forces, 
the increase of uterine irritability at the recurrence of the men- 
strual epochs, probably accounts for the ordinary coincidence of 
labor with the tenth eatamenial date. 

The Expelling Powers. — The powers which unite to expel 
the foetus, are to a great extent, vested in the uterine unstriped 
muscular fibres. Auxiliary aid is afforded by the vaginal and 
abdominal muscles. 

The Uterine Contractions. — The uterine muscles act in such 
a way that with each contraction the shape of the organ is more 
or less altered. Its general form toward the close of gestation is 
oval, but while in a state of contraction, the longitudinal and 
transverse diameters are diminished, while the antero-posterior 
is increased, giving the organ a globular shape. Uterine action 
is always of an intermitting character, the intervals at first being 
wide, but gradually lessened as parturition proceeds. The con- 
traction is of a peristaltic nature. Beginning at the fundus it 
extends downwards like a wave till it reaches the cervix uteri, 
and then returns again to the fundus, during which time the 
uterus remains in a state of firm contraction. This peristaltic 
wave, however, extends so rapidly that the organ may be justly 
regarded as a hollow muscle which contracts simultaneously in 
all its parts. The action is generally accompanied with pain, at 
first of a cutting and sawing kind, and later of a bearing and dis- 
ruptive nature, though some women pass through parturition 
with very little suffering. With regard to the direction and ori- 
gin of the contraction waves which pass over the uterus, it should 
be added that there is a lack of concord among obstetricians, 



UTERINE CONTRACTIONS. 279 

some believing that the contractions of the uterus do not begin 
in the fundus, but in the os uteri, and pass from one extremity 
to the other. It is claimed by such that the os uteri is first felt 
to contract, and then follow evidences of extension upwards of 
the action. This, however, does not at all accord with the 
author's experience. As the fingers rest against the presenting 
head, the first evidence of uterine action communicated through 
the sense of touch, is a descent of the part, showing clearly that 
the contraction begins at the distal pole. Another point worthy 
of observation is that when the uterus goes into a state of con- 
traction, if one hand be placed over the fundus, while the other 
feels the cervix, it will be noticed that hardening is first felt at 
the fundus, followed by contraction of the os uteri. 

As in the case of almost all unstriped muscular fibres, reflex 
action following upon irritation is gradual, and varies in intensity 
and duration according to the degree of irritation. A certain 
amount of irritation is necessary to cause a contraction, and as 
the stimulus is at first mild, the resulting contraction is also fee- 
ble. Moreover, the interval between contractions is long, as 
some time is required to accumulate the necessary sum of stim- 
ulation. With the increasing separation of the membranes from 
the uterine wall, and escape of the liquor amnii, the irritation is 
augmented, the uterine action gains in strength and duration, 
and the intervals are much abbreviated. At the acme of the 
propulsive stage, the stimulation is so considerable that the con- 
tractions are broken only by short pauses. The stronger the 
pains, the shorter the interval between them. The average nor- 
mal duration of a labor pain is little less than one minute. In- 
asmuch as the motor centres of the uterus are located mainly in 
the sympathetic ganglia, the action is involuntary. Contractions 
come and go without regard to the volition of the woman whose 
fortune it is to suffer them. Mental excitement has been observed 
to have a modifying effect, and it has been suggested that the 
anterior sacral nerves may perform an inhibitory office. 

The presenting part of the foetus, or the bag of waters, is 
forced by the contractions of the uterus against the internal os 
uteri, to forcibly distend it. The cervical canal thus becomes 
a part of the uterine cavity, and then the external os is expanded 
by a similar mechanism. As dilatation of the os proceeds, its 
margins become thinner, until they are almost membranous. 






280 LAB OK. 

when finally retraction from the fcetal head takes place. The 
uterus and vagina now form the fully expanded parturient canal, 
and expulsion of the foetus proceeds. 

Uterine contractions vary much in intensity, both in different 
cases, and the various stages of the same case. Attempts have 
been made to approximately measure the different degrees of 
force exerted in the accomplishment of parturition. While the 
results of such researches and experiments have not been highly 
satisfactory, they may be accounted valuable data. Dr. Matthews 
Duncan, after repeated experiment and study, found the force 
requisite to rupture the strongest membranes, with an os uteri 
4.50 inches in diameter, was about 37 J lbs. He collects, further, 
that, in ordinary labor, the propelling force is from six to twenty- 
seven pounds.* In cases where unusual effort is made, the pro- 
pulsive power exerted by the uterus, the abdominal walls, and 
the other forces at the woman's command, may be increased to 
eighty pounds, f The combined parturient energy has been cal- 
culated by Schatz, J at from seventeen to fifty-five pounds. Prof. 
Houghton's estimates are far in excess of these. 

Influence of the Pains on the Organism. — During a pain 
the arterial pressure is increased; the pulse is accelerated several 
beats per minute until the acme is reached, when it slowly de- 
clines to a normal point. The respirations are generally slowed, 
though they are sometimes considerably accelerated, especially 
in nervous, sensitive women. The temperature is slightly ele- 
vated, and the urinary excretion, in consequence of the increased 
arterial pressure, is augmented. § 

Contractions of the Uterine Ligaments. — Structurally, the 
muscular fibres of the round and broad ligaments are continua- 
tions of the external muscular layer of the uterus. As would be 
anticipated, they contract simultaneously with that organ. In 
contracting, they fix the uterus at the pelvic brim, while the 

* " The strongest membrane found in the experiments indicated, by the pres- 
sure required to burst it, an extruding force of 37 1 lbs. We may therefore, I 
think, safely venture to assert, as a highly probable conclusion, that the great 
majority of labors are completed by a propelling force not exceeding 40 lbs." 
" Researches in Obstetrics," p. 319. Duncan. 

f " Researches in Obs.," p. 323. 

t Vide Schroedee. '• Lehrbuch," 6te Aufl., p. 158. 

§ Naegele. " Lehrbuch der Geb.," p. 163. 



ABDOMINAL AID. 281 

round ligaments serve additionally to incline the fundus forward. 

The Yaginal Contractions. — As the foetus passes through 
the os uteri into the vagina, the latter organ at first resists its 
progress, but the walls ultimately expand to receive and transmit 
the body that seeks exit. The tube then at first not only does 
not facilitate labor, but actually impedes it; but after the greatest 
diameter of the foetus has passed the sphincter vaginae, expulsion 
is materially aided by contractions of that muscle. The same 
fibres also aid in extruding the secundines. 

Abdominal Aid. — The aid afforded by the abdominal muscles 
has a marked effect on the progress of labor. This action differs 
from that of the uterus, in that it is largely voluntary; still, at 
the height of a pain, the vehemence of uterine action provokes 
a kind of general tenesmus, which is irresistible. Abdominal 
pressure acts in the following way : The extremities are pressed 
against some firm support, and the trunk is thus fixed; by deep 
inspiration the diaphragm is pushed downwards; the abdominal 
muscles then contract, and the diaphragm, which descends still 
further, partly from its own contraction, but chiefly by the pow- 
erful action of the expiratory muscles, exerts an equable pressure 
on all the abdominal contents. Abdominal aid, however, cannot 
be exerted in an effective manner until there has been some de- 
scent of the uterine tumor, as the contraction of the transversalis 
muscle would manifestly operate as a constriction, without de- 
cidedly promoting expulsion. Aid from the abdominal muscles 
should not be evoked until the propulsive stage has been inau- 
gurated, when it will prove most helpful. 

The Pains of Labor. — The location and character of labor- 
pains vary not only with the parturient stages, but also with the 
woman's peculiarities. During the first stage, or stage of uterine 
dilatation, the suffering is of a cutting, sawing or grinding nature, 
and is generally referred to the hypogastric, or lumbo-sacral 
region, or to both. From the back, the pains radiate forwards 
and downwards, into the abdomen and thighs. The hypogastric 
pains extend into the groins. During the second stage of labor, 
the lumbo-sacral region is, as a rule, the seat of greatest suffer- 
ing, until, toward its close, it is transferred to the sacrum, rectum, 
and vulva. The pains themselves are greatly changed during 
this part of labor, being of a tearing, distensive, luxative charac- 



282 LABOR. 

ter. Dr. Meigs* offers some very excellent observations on this 
topic. " The pain felt in labor," he says, "is owing to the sensi- 
bility of the resisting, and not to that of the expelling organs. 
Thus the sharp, agonizing and dispiriting pains of the commence- 
ment of the process, which are called grinders, or grinding pains, 
are surely caused by the stretching of the parts that compose the 
cervix and os uteri and upper end of the vagina. Pains are 
rarely felt in the fundus and body of the organ; and nineteen 
out of twenty women, if asked where the pain is, will reply that 
it is at the lower part of the abdomen, and in the back, — indicat- 
ing, with their hands, a situation corresponding to the brim of 
the pelvis, and not higher than that, — a point opposite the plane 
of the os uteri. When the pains of dilatation are completed, and 
the f cetal presentation begins to press upon the lower part of the 
vagina, the pain will, of course, be felt there, and is finally 
referred to the sacral region, the lower end of the rectum, and 
perineum. The last pains, which push out the perineum, and 
put the labia on the stretch, will of course be felt in those parts 
chiefly. The sensation, under these circumstances, is repre- 
sented as absolutely indescribable, and certainly as comparable 
to no other pain." 

In a fair view of all the facts, it does not seem probable that 
the foregoing is altogether true. Seasoning from analogy, we 
conclude that a forcible contraction of an organ like the uterus 
is, in itself, productive of more or less pain. This inference is 
justly derivable from a study of after-pains, and from violent 
contractions of other organs. In this connection there are other 
data of importance. The phenomenon of misplaced or metas- 
tatic labor-pains is occasionally observed. The pain, instead of 
being in its usual locations, is felt mainly, or exclusively, in 
other parts of the body. The head may be the point of attack, 
the eyes, or the legs, indeed almost any part. Dr. B. Fordyce 
Barker reported a case to the New York Obstetrical Society,f in 
substance as follows : He recently attended a lady in her con- 
finement who was in labor but two hours, though the pains did 
not seem at any time to centre about the pelvis. There were no 
uterine pains at all, but with each contraction of the womb, pain 
was experienced in the legs. The pain was not localized, nor 

*"Systemof Obs.," 1863, p. 281. 
tAm. J. Obs., Vol iv, p. 727. 



PHENOMENA OF LABOR. 283 

was there any muscular contraction in the legs. The same pain 
was produced in pressing off the placenta. Weigand relates a 
case in which severe infra-orbital pain occurred with every uter- 
ine contraction. Dewees mentions one in which the pains were 
felt in the calves of the legs. A very interesting example of 
misplaced labor-pain is reported by Prof. R. Ludlam, and made 
a text for some instructive remarks." 1 " 

It will be clear from what has been said regarding the nervous 
supply of the uterus and other pelvic organs, under its proper 
head, that the organ may act in a regular and orderly manner, 
while the pain incident thereto may be reflected to other and 
distant parts. 

The terms "forcible pains," "weak pains," "deficient pains," 
etc., are commonly used. The substantive "pain" is h«re syn- 
onymous with " contraction." Pain is merely the sensible evi- 
dence of uterine action. When the organ acts with energy, the 
pains are generally severe; and when it acts feebly, the pains 
are correspondingly light. The terms "vehement," "powerful," 
"forcible," "weak," "deficient," " inefficient," etc., are only rel- 
ative, that is to say, they do not express a definite degree of 
either quantity or quality. 



CHAPTEE II. 

Clinical Course of Labor, and its Phenomena. 

The Stages of Labor. — Having given the physiological facts 
in connection with labor pains, we may now proceed to describe 
the clinical course of a natural labor, with the vertex presenting. 

Careful observers of the sequence of events in labor have not 
failed to notice that the process is very naturally divided by 
the phenomena presented, into three'stages, namely, theirs/, or 
preparatory stage, in which expansion of the os uteri is effected, 
and the parts prepared for descent of the head through the par- 
turient canal; the second, or propulsive stage, during which the 

+" Diseases of Women," 1881, p. 326. 



284 PHENOMENA OF LABOR. 

foetus is expelled; and the third, which comprises the separation 
and expulsion of the secundines. The first stage ends, then, 
with full dilatation of the os uteri, the second beginning there 
and closing with expulsion of the foetus, and the third terminat- 
ing with complete evacuation of the uterus. 

The Preparatory Stage. — The first stage of parturition is 
said to begin with the first symptoms of actual labor, but the 
exact moment when this occurs is not always easily determined. 
There is a certain amount of preliminary action which has very 
properly been termed the 'preparatory stage. This is sometimes 
well marked, while at other times it is so indistinct that it escapes 
notice. One of the most common changes occurring toward the 
close of pregnancy is what has been elsewhere alluded to as sub- 
sidence of the uterus, with a falling forward to a certain extent 
of the fundus. This change of situation is followed by consid- 
erable relief to respiration, and to the gastric disturbances which 
are so liable to afflict the woman in the latter weeks of preg- 
nancy. Locomotion is made more difficult, the downward press- 
ure of the gravid uterus produces a frequent desire to urinate, 
and, often, to defecate. From a similar cause, hemorrhoids are 
many times either developed or aggravated. In primiparae the 
presenting head generally lies lower within the pelvic cavity 
than in multipara. For a variable time before the advent of 
real labor-pains, there is usually a muco-sanguineous discharge 
from the vagina, and premonitory pains and aches are experi- 
enced, especially by multipara. The woman feels a sensation 
of dragging in the sacrum and pubis, and of tension in the ab- 
dominal region. As a result of the painless, or slightly painful, 
uterine contractions, which are observed throughout the greater 
part of pregnancy, and an aggravation or augmentation of which 
constitutes labor, the cervical canal may be dilated to a consid- 
erable extent, in multipara, for days, or even weeks, before 
labor. 

False Labor- Pains. — The moderate, intermittent, and usu- 
ally painless, contractions of the uterus, just alluded to, may in 
some women of susceptible natures, give rise to suffering, and 
constitute what are known as false pains. These, however, we 
believe to be a comparatively infrequent cause of the sensations 
thus designated. False pains are usually irregular, often strong 
at first, but gradually becoming weaker; are limited in extent, 



THE FIKST STAGE. 



285 



rarely dilate the os or protrude the bag of waters, and are not 
generally accompanied by the muco-sanguineous discharge be- 
fore mentioned as preceding real labor. They arise from indi- 
gestion, cold, movements of the foetus, and various other causes, 
but are usually relieved by rest, and the administration of caul- 
ophyllum, Pulsatilla, or other remedies calculated to remove the 
cause upon which they depend. 

The First Stage. — In a certain proportion of cases labor may 
set in abruptly, with severe and quickly-recurring pains, but as 
a rule the onset is gradual, and the pains so far apart as to 
amount to nothing more than a little uneasiness, leaving the pa- 
tient in doubt as to their real significance. Painful contractions, 
however, soon ensue, making the woman restless, and disposing 

Fig. 114. 




Section showing the foetus, inclosed in its membranes, with expanding os 



her either to bend forward with clinched hands, or to seek some 
firm support for the sacrum in the vain hope to find relief. But 
women greatly differ, in their natural sensibility to pain, and 
their power to endure it. Some will toss about with every liter- 



286 PHENOMENA OF LABOR. 

ine contraction, and evince the most intense agony, while others 
will utter scarcely a groan. The cases of painless labor are few 
indeed, while instances of terrible suffering are numerous. 

It is both interesting and instructive to observe the various 
positions taken by women in the different stages of labor. In 
the early part of the parturient act, the sitting posture is most 
commonly chosen, with the hands pressed upon the hips during 
a pain, while the body is bent somewhat backward. 

The pains of labor may be said to begin with the dilatation of 
the internal os, and the expansion there begun, progresses gradu- 
ally until the entire cervical canal becomes large enough to ad- 
mit of expulsion of the uterine contents. As the os internum 
opens, the contractions cause the membranes to descend and ex- 
ert an expansive force on the cervical canal. During a uterine 
contraction, the membranes are observed to become tense, and 
to bulge, until, after a certain amount of expansion has been at- 
tained, in shape they resemble a watch crystal. This is true, 
however, only after the internal 'os has entirely yielded, and the 
edges of the external os are thinned from the pressure put upon 
them. As the pain subsides, the os relaxes, and the membranes 
retreat. With the advance of labor, the pains increase in in- 
tensity and frequency, and uterine dilatation is usually progres- 
sive. Nausea and vomiting are not infrequent, but, when pres- 
ent, add greatly to the woman's distress. When not too pro- 
longed, they need not be regarded as at all alarming. The soft- 
ening, relaxation and hypersecretion of the soft structures be- 
come more and more decided, and when the expansion has 
reached a certain limit, say a diameter of two and a-half or 
three inches, the protruding membranes generally rupture 
spontaneously, and a considerable part of the liquor amnii es- 
capes with a gush, but a certain portion of it is generally re- 
tained by the presenting head, which acts as a ball valve at the 
pelvic brim. If they do not, the attendant usually finds it ad- 
visable to rupture them. 

The pulse generally increases in frequency in proportion to 
the severity of each pain, only to decline again in the interval. 
This effect on the circulatory apparatus may be usefully em- 
ployed as a guage of the efficiency of the pains, for the more 
marked and uniform the variation, the more effective the pain 



PHENOMENA OF LABOR. 
Fig. 115. 



287 



Ooeliac.A, 

Sup.McscnM. 
V. Porta} 




Ext. Os Uteri 



Kectum 



Liquor Aiunii 



Section of a frozen body at the termination of the first stage of labor. The 
membranes are still intact, the cervix is fully dilated, and the head, occupy- 
ing the second position, is in the pelvic cavity. 



288 



PHENOMENA OF LABOR. 



which causes it. "When, however," says Hohl,* "the rapidity 
of the beats subsides before approaching the maximum, the pain 
is too weak; or when the rapidity rises by sudden starts, the 
pain is a hurried one, and in either case its effect will be imper- 
fect." The pulse acceleration, under an efficient pain of average 
duration, he represents by the following record of the several 
quarters of two minutes: 

18, 18, 20, 22 : 24, 24, 22, 18. 
Contrary to the teaching of some observers, our experience 
has taught us that the effect of uterine contractions on the f oetal 

Fig. 116. 

V i 




The Parturient Canal. 

heart is usually one of retardation rather than acceleration. 

The softening, relaxation, and hypersecretion become more 
and more decided. When distension of the os becomes exces- 



Vide Irishman's "System of Midwifery," p. 253. 



THE MECHANISM OF DILATATION. 289 

sive, slight lacerations occur, the blood from which, together 
with that from ruptured decidual relations, oozes from the geni- 
tal fissure, or stains the examining fingers. After a time the 
head, influenced by the uterine contractions, descends into the 
cervix, the walls of which are separated until they lie against 
the pelvic borders, and thereby form, with the uterine cavity 
and vagina, a continuous channel known as the parturient canal. 
This, the first stage of labor, varies greatly in duration, but is 
generally completed in six or seven hours. It sometimes lasts 
but an hour, and, on the other hand, it is occasionally protracted 
to one, two or three days. 

The Mechanism of Dilatation.— It appears to have been 
pretty generally conceded that the so-called "bag of waters" 
acts as a kind of entering wedge, by means of which an equable 
hydrostatic pressure is brought to bear in the direction of ex- 
pansion, and that this is the mechanism through which dilata- 
tion of the os uteri is mainly effected. Leishman* reasons 
learnedly and forcibly on the subject as follows: "The first 
efficient contraction having resulted in an opening of the os to 
a trifling extent, and the tissues being sufficiently relaxed to ad- 
mit of satisfactory progress, we are enabled to trace the process 
of dilatation through all its subsequent stages. As soon as the 
os has yielded to a certain extent, the membranes which are 
here separated from their uterine attachment, commence to pro- 
trude in the form, first of a watch-glass, and then of the ex- 
tremity of a pouch or bag, which has been termed the 'bag of 
waters.' Following the operation of a very obvious law already 
alluded to, this phenomenon implies, primarily, an attempt, con- 
sequent on the uterine contraction, on the part of the waters, to 
escape in the direction in which resistance is least. The special 
function, however, of this bag is to effect the further dilatation 
of the os, and we can conceive no means which could be more 
admirably adapted to this object than the graduated fluid pres- 
sure which is thus brought to bear upon the os equally in its 
whole circumference. It constitutes, in fact, in its action dur- 
ing a pain, a hydro-dynamic force, which acts at once safely and 
powerfully upon the whole of the os." Theoretically this action 
of the bag of waters is very decided, but when we reflect upon 

* " System of Midwifery," p. 254. 



290 PHENOMENA OF LABOE. 

all the circumstances, including the non-existence of the bag of 
waters in a large share of cases, in which labor progresses fa- 
vorably and rapidly through the first stage, we are led to con- 
clude that the mechanism of os dilatation described, is not 
altogether the true one. The chief discrepancy probably lies 
in attributing the main expansive force to the pressure of the 
bag of waters, instead of the foetal head, or other presenting 
part. Dilatation of the os is sometimes considerably accelerated 
by early rupture of the membranes, and escape of the liquor 
amnii. * 

The subject is further elucidated by Lusk.* " The dilatation 
of the cervix," he says, "is partly mechanical, and partly the 
effect of certain organic changes which have already received 
cursory mention. 

The mechanical dilatation is the result of — 1. The pressure of 
the ovum upon the lower uterine segment, which forces open 
the os internum, and unfolds the cervix from above downward. 
2. The retraction of the uterus, an important property which 
requires brief description. While each contraction of the ute- 
rus is followed by relaxation, and a period of repose, a gradual 
change is continually going on in the length and arrangement of 
the muscular fibres. In the thinned lower segment the fibres 
are stretched, and separated from one another. In the upper 
portion, on the contrary, they shorten, and change their 
position in such a way that those which previously had only 
their extremities in contact, assume a more nearly parallel 
arrangement. The walls, therefore, in the upper zones, 
thicken, and shorten, especially in the longitudinal direction. 
The limit between the thinned lower segment and the upper 
thickened zone is marked by a distinct ridge termed the ring of 
Bandl. It is to the changes in the uterus which take place 
above the ring of Bandl that the term retraction is applicable. 
As the retraction is progressive, it leads to a gradual withdrawal 
upwards of the uterine walls, in consequence of which the 
lower segment is not only put upon the stretch during the pains, 
but, toward the end of the period of dilatation, is subjected to 
a greater or less degree of permanent tension. Then, too, as 
the ring of Bandl moves upward, the longitudinal fibres of the 

* " Science and Art of Midwifery," p. 136. 



THE MECHANISM OF DILATATION. 



291 



lower segment, by reason of their insertion in part at least into 
the vaginal portion, exert a direct influence in dilating the cer- 
vical canal. 

"3. \Then the abdominal muscles contract, the uterus is pressed 
downward into the pelvic cavity. The descent is, however, lim- 
ited by the attachment of the uterine ligaments, and the adja- 
cent organs. But the resistance afforded by the uterine attach- 
ments exercises a peripheral traction upon the cervix, and thus 
tends to draw its walls asunder." 



Fig. 117. 



pancreas 



_ft. coeliafl 
aumes. sup. 



mMsSsBmMMi-- v. port. 



placent 



- duodenum 



placenta. 



Cgf.tub 




©tif ut. int. 



The uterus and parturient canal, — foetus removed. 

Rupture of the membranes usually occurs spontaneously, as 
stated, about the close of the first stage, marking a complete 



292 PHENOMENA OF LABOE. 

dilatation of the os uteri; but when unusually tough, they may, in 
neglected cases, continue to surround the foetus till after its 
expulsion. A child thus enveloped is said to be born with a 
" caul." What is even more common, however, is a rupture of 
the membranes at the point where they surround the neck, and 
a retention of the detached portion over the face, constituting a 
"veil," which old nurses regard as a sign of good luck. 

The Second Stage, or Stage of Propulsion.— At this stage 
the os is completely dilated and somewhat retracted so as scarcely 
to be felt. The pains begin to assume a different character. 
The uterus contracts more closely on the foetus, and pushes it 
downwards into the pelvic cavity. The woman now begins to 
feel the presence of a solid body which must be expelled, and 
she accordingly bends every endeavor to the consummation of 
the undertaking. The pains are now really much more painful, 
but the consciousness that they are accomplishing something 
seems to infuse both strength and fortitude. The powerful pro- 
pulsive efforts made by the woman are termed " bearing down," 
propulsive, or expulsive, and hence the name often given to this 
stage of labor, namely, the propulsive. The resistance encoun- 
tered in the first stage has been removed by the completion of 
dilatation, and now the pelvic brim, the varied relative diameters 
of the pelvic cavity, the pelvic floor, vagina and vulva, resist 
rapid progress. If the pains are powerful, and the resistance 
great, tumefaction of the foetal scalp is likely to ensue at the 
point of least resistance, such a swelling being known as the 
"caput succedaneum." Each pain causes the head to descend 
lower and lower, until it comes to press against and distend the 
perineum. The head advances during a pain, and recedes as 
the pain passes off, but makes a sensible gain each time. The 
recession is a wise provision of nature to prevent continuous 
pressure at any one place, as well as to obviate too rapid disten- 
sion of the soft structures. The rectum becomes flattened, and 
its contents expelled by the advancing head. Such pressure and 
distension open the anus to a considerable extent, and thin and 
elongate the perineum. As the foetal head enters the pelvic 
brim, with the occipital pole of its long diameter in advance, a 
condition of firm flexion of the chin on the sternum is enforced. 
The long diameter of the head, lying in an oblique diameter of 
the pelvis, a movement occurs in the pelvic cavity, by means of 



THE SECOND STAGE. 



293 



which the long diameter of the vertex is brought into the conju- 
gate of the outlet. This movement is termed rotation, and the 
time for its accomplishment is when the head is pressing firmly 
against the pelvic floor, and the perineum is thereby made to 
bulge. The vulvar opening is put more and more upon the 
stretch, as the head emerges; the woman gathers her energies 
for every pain, and presses as forcibly as her strength will per- 
mit; while now and then she gives vent to her terrible sufferings 
in an agonizing cry. The straining efforts of the woman are in 
a measure under her control. They are intensified by her inflat- 
ing her lungs, and forcibly holding her breath, while she bears 
down; but by opening the mouth and giving expression to her 
feelings in cries, the abdominal muscles are relaxed, and the 
straining efforts modified. The head finally passes the vulva, 
and the woman experiences a great sense of relief, which is soon 
disturbed by a pain that brings the foetal body wholly into the 
world. The expulsion of the child is followed by the outpour- 
ing of the amniotic fluid, which is generally reddened by blood 

Fig. 118. 




Distension of the Perineum (Hunter.) 

from the vessels lacerated by partial or complete separation of 
the placenta. The pains then cease, and the relief experienced 
by the woman is most delicious. Some compare their feelings 
to a real foretaste of heaven, or give expression to their exper- 
iences in other words equally glowing and emphatic. 
The duration of the second stage of labor is exceedingly varia- 



294 PHENOMENA OF LABOR. 

ble. It is occasionally completed in twenty or thirty minutes, 
while in many cases it lasts several hours. 

The Third Stage. — The placenta is sometimes separated dur- 
ing the latter part of the second stage, and follows the foetus, 
being expelled by the same contraction which terminates that 
part of labor. This, however, is rather unusual, the phenomena 
of the third stage being such as are below described. The third 
stage of labor begins immediately after complete expulsion of 
the foetus. Contrary to the generally-received opinion, it is 
attended with more real danger to the woman than either of the 
others mentioned. It is during this part of labor that the vas- 
cular relations between fcetal and maternal structures are sev- 
ered, and on the perfect and harmonious action of the natural 
forces, closure of the uterine sinuses is effected, and the woman 
protected from fatal hemorrhage. 

Birth of the child is often followed by syncopal sensations, 
arising from recession of blood from the brain, occasioned by 
removal of the intra-abdominal pressure. Soon after comple- 
tion of the third stage women occasionally suffer a chill, or, 
what is of more frequent occurrence, a protracted nervous tre- 
mor, entirely out of proportion to the chilliness felt. This how- 
ever need cause no apprehension, unless distressingly severe, or 
long-continued, as it is merely the result of vaso motor disturb- 
ance, and the loss, through foetal expulsion, of a source of heat- 
supply. 

There is usually an interval of repose, of varying duration, 
followed by one or more uterine contractions of some force, 
which suffice to expel the retained secundines. In unassisted 
cases the placenta may be expelled into the vagina and lie there 
for hours, or even days. The contracting uterus follows the 
foetus during expulsion, until after close of the third stage it 
will be found like a hard ball, in the hypogastrium. This action 
of the uterus causes separation of the placenta, detachment 
occurring in the meshy, lamellated layer which is formed in the 
serotina by the thinned, elongated walls of the gland tubules, 
the dense cell-layer which forms the maternal portion remaining 
adherent to the placenta. As such separation involves rupture 
of the maternal vessels, some hemorrhage always follows the 
detachment, but is rarely profuse, inasmuch as the very condi- 



THE THIBD STAGE. 



295 



tions which serve for separation of the placenta, likewise com- 
press the broken vessels, and control the escape of blood. 
Fig. 119. Fig. 120. 





Normal mode of separation 
and expulsion of the placen- 
ta. 



Mode of separation and ex- 
pulsion when traction is made 
on the cord. 



Much emphasis has of late been put upon the mechanism 
of placental expulsion as elucidated by Dr. Matthews Duncan 
and others. It is held by them, — and their views are now gen- 
erally accepted, — that when no traction is put upon the umbili- 
cal cord, the placenta issues from the uterus edgewise, though 
it may be folded longitudinally; but when it is drawn out by 
traction on the cord, inversion occurs, and, from the suction 
action thus imparted, the difficulties of delivery and the dan- 
gers of hemorrhage are augmented. 

Gassner* found that after confinement, the female experiences, 
as a consequence of the expulsion of the ovum, of the exhalations 
from the lungs and skin, from the discharge of excrements, from 
loss of blood, and from other depletions, a loss of weight equiv- 
alent to one-ninth of that of the entire body. 

* " Ueber d. Veriinderungendes Korpergewichtes b. Schwang., Gebiir, und 
Wochner," Monatsschr. f. Geburtsk., xix, p. 18. 



296 PHENOMENA OF LABOR. 

Duration of Labor. — Labor differs so greatly in duration that 
it is almost impossible to deduce from observation any impor- 
tant truths concerning its length. It may be said, however, 
that, in general, it is longer in primiparse than in multipara, on 
account of the greater firmness of the soft structures. It is also 
observed that, other things being equal, the pains and difficulties 
of first parturitions increase, with age. The relative depth of 
the pelvic cavity has a modifying influence upon labor, and 
accordingly it is found that very tall women pass through the 
ordeal with less facility than others. On the contrary, short, 
stout women, with considerable adipose tissue, also suffer long 
labors, owing to the firmness of their tissues, and the presence 
of an unusual quantity of fat in the pelvic cavity. The charac- 
ter of labor is subject to modification by the position and pres- 
entation of the fcetuSc Presentation of the face for example, is 
attended with greater difficulty than that of the vertex, and an 
occipito-posterior position is more unfavorable than an occipito- 
anterior. Other modifying conditions are often found to exist, 
as the presence of various tumors, and the contraction of the 
pelvic diameters, etc. 

People are prone to think that it is within the power of the 
physician of skill and learning, to foretell the exact duration of 
labor, a thing, by the way, which he is not capable of doing. 
The pains may be vigorous, the tissues relaxed, and everything 
progressing in a satisfactory way, when the uterine contractions 
may suddenly weaken, or utterly cease for many hours, or some 
other unfortunate occurrence may interpose to interrupt the 
regular course of nature. 

When the woman can be truthfully assured that everything is 
favorable, it is incumbent upon him to discharge his obligation. 
To the importunate appeal — " Doctor, how soon will it be over? " it 
is better to evade positive reply. The duration of labor, while it 
may be predicted with considerable accuracy in a certain num- 
ber of cases, manifestly depends upon so many contingencies, 
that truthful predictions should not be attempted, and, in gen- 
eral cannot be made. The relative duration of the first and sec- 
ond stages is by some stated to be in the proportion of two or 
three to one, but others believe it is nearer four or fixe to one, 
the first stage being the longer. It is sometimes much shorter 
than the second. 



THE HOUK OF LABOK. 297 

The Hour of Labor. — The larger number of births is said to 
take place in the early morning hours. West* observed that 
out of 2019 deliveries, 780 occurred between 11 p. m. and 7 a. m. ; 
662 from 7 a. m. to 3 p. m. and 577 from 3 p. m. to 11 p. m. 
Kleinwachter f tells us that labor-pains usually set iia. be- 
tween 10 or 12 p. m. Spiegelberg J believes the maximum fre- 
quency of birth is between 12 and 3 o'clock. 

The Influence of the Tide on Parturition.— Dr. G. G. Eaue 
in 1865 § called attention to this subject, and reported his obser- 
vations in thirty-four cases, in which, with a single exception, 
he found that birth took place at high tide. Dr. T. S. Hoyne|] 
found in seventy-five cases but four exceptions. 

Dr. M. M. Walker has prepared a paper on the subject for the 
Horn. Med. Society, of Penn., (Sept. 1882,) with a report of 200 
cases, from which the following figures, by the Doctor's courtesy, 
have been taken: 

Number born during solar and lunar flood tides combined, - - 42. 

" " solar flood, - 52. 

" " " lunar flood, - - - - 38. 

Total born during the flood tides, - 132, or 66 per cent. 

" " ebb tides, and at other times, 42, or 21 per cent. 

Instrumental cases and extractions, - - 26, or 13 per cent. 

Three cases born during the administration of an anaesthetic, without instru- 
mental aid, and included in the above table, occurred as follows : one during 
both solar and lunar flood, one during lunar flood, and one during ebb tide. 
These two hundred consecutive cases occurred from Nov. 1874 to Aug. 1881. 

* American Medical Journal, 1854. 

f Diezeit der Geburlsbeginnes, " Ztschr, f. Geburtsh, Bd. 1 p. m. 

X Lehrbuch, etc., p. 135. 

$ " Hahnemann ian Monthly," vol. i. 

|| " The Clinique," vol. ii. p. 400. 



298 THE MANAGEMENT QF LABOR. 



CHAPTEE III. 

The Management of Normal Labor. 

Having given a brief account of the phenomena usually ob- 
served in labor of a normal character, it becomes necessary to 
offer some observations on the management of the various 
stages of the parturient process. So wisely has nature adapted 
means to ends, that the act throughout is generally one which 
requires but little direction, and still less assistance, from the 
medical attendant. So true is this that we might add that, in 
the vast majority of cases, as happy and satisfactory an issue 
results under the care of an uneducated, but experienced, at- 
tendant, as under the conduct of those consummately learned, 
and highly skilled. But irregularities in the parturient act are 
liable to arise, in the management of which the highest attain- 
ments are essential. Complications when they are met, however, 
cannot be successfully mastered without a thorough acquaint- 
ance with the phenomena of the normal process which have al- 
ready been described. 

Preliminary Arrangements.— Within the scope of these 
suggestions regarding the management of labor, should be in- 
cluded mention of certain preliminaries, respecting which women 
often require some advice. In their proper place, observations 
respecting exercise and care of the bowels have been made, but 
we ought here to add that the woman should give especial atten- 
tion to the observance of these. In no case should the custom- 
ary stool be neglected when labor is at hand, and if there is the 
slightest tendency to constipation, as soon as pains are experi- 
enced a large enema should be taken and the bowels emptied, 
which will facilitate fcetal expulsion, and at the same time ren- 
der the necessary attentions of the accoucheur less disagreeable. 

Under the same head, we may call the physician's attention 
to the advisability of ever holding himself in readiness to attend 



HOW TO APPEOACH THE PATIENT. 299 

midwifery cases, in order that no unnecessary delay may ensue. 
It is true that in the majority of instances there is no occasion 
for haste, but in many cases successful results are dependent 
mainly on the physician's promptitude in responding to the ur- 
gent call. 

Prompt Response to Calls.— The practitioner will often be 
subjected to the annoyance of being called before labor has ac- 
tually begun, but this fact should make him none the less atten- 
tive and prompt. It is of the highest importance that abnor- 
malities of foetal form, presentation, or position, and unfavora- 
ble maternal conditions, be recognized at the earliest possible 
moment, since this places the accoucheur in a position to lei- 
surely determine upon a plan of treatment^ to provide himself 
with the best facilities, and to choose the most desirable moment 
for interference. 

Armamentarium. — If the case to which he is called is likely 
to be difficult, the forceps and the perforator may be carried. 
Indeed, if the call is to take him a considerable distance from 
home,- it is the part of prudence to take along such instruments 
as may be required in emergencies. The physician in active 
obstetrical practice will do well to provide himself with a bag 
or case of obstetrical instruments, which should include a good 
pair of long forceps, a perforator, a pair of craniotomy-forceps, 
a crotchet, a right-angled blunt hook, a decapitating hook, 
and a soft rubber catheter. Beside these he should have a 
pocket-case of instruments, a hypodermic syringe, and a quan- 
tity of chloroform. He should provide himself also with a case 
containing, in addition to the most common homoeopathic rem- 
edies, a reliable preparation of fluid extract of ergot. 

How to Approach the Patient. — There is no subject con- 
nected with midwifery practice, instruction concerning which 
would be more acceptable than this, and yet it is one upon which 
very little satisfactory instruction can be given. The fact is, that 
the etiquette of the lying-in-chamber is founded upon the same 
general principles of deportment which govern the polite rela- 
tions of life. Gentlemanly demeanor is about all that is re- 
quired to insure mutually agreeable contact. The caprices of 
woman during labor are greatly augmented in number and vol- 



300 THE MANAGEMENT OF LABOR. 

urne, and the most considerate conduct on the part of the phy- 
sician will sometimes be met with repulse. 

Women in parturition watch every movement, and mark every 
word of their medical attendant, so that his tact then, as per- 
haps at no other time, is put to a crucial test. Nor can their 
likes and dislikes, their opinions and their whims, be put into 
one general class and treated alike. Here, as elsewhere, to in- 
sure the best results one must individualize, and he who does so 
best, will achieve the most perfect results. 

The following advice, given by the erudite and urbane Dr. 
Blundell,* is thoroughly practical and sensible: "If you are 
well known to your patient," he says, "on reaching the house 
you will be welcome to her apartment; but if you have not fre- 
quently seen her before, nor attended her on former occasions, 
I would recommend you not immediately to pass into her cham- 
ber. Not having her full confidence, by your presence you 
might agitate her, and in these cases it is proper to avoid every- 
thing that may produce commotion of the nervous system. It 
is better, therefore, that the accoucheur retire into some adjoin- 
ing room, where he may see his lady patroness, the nurse, who 
has generally a great many foolish things to gay, all of which he 
may as well hear with patience and bonhommie. When the 
shower of words is blown over, or when Mrs. Speaker reluctantly 
pauses to draw breath, dexterously seizing the auspicious mo- 
ment, you may make inquiries respecting the progress of the la- 
bor, the condition of the bladder, the state of the bowels, and so 
on; questions which, in ordinary cases, may with more delicacy 
be proposed to the nurse than to the patient herself. Should 
you chance not to be a dear man, a pious man, a good kind crea- 
ture, or, still worse, should the lady be pettish, and declare you 
to be a brute or a physiologist, so that for these manifold of- 
fences she never, never will — never can see you — you may re- 
main in the house, as the female "never" in these cases comprises 
but a small portion of eternity, perhaps on an average, some 
one or two hours, and when caprices and antipathies are a little 
subdued by the pains, your presence will be cordially welcome. 
Now, then, the pains being severe, after you have entered the 
room, you may make your examination, and if you find the labor 

* " BlundeU's Midwifery," 1842, p. 96. 



THE EXAMINATION. 301 

rapidly advancing, you must remain at the bedside lest the child 
should come into the world in your absence." 

The Examination. — When shall it be made? The stage of 
advancement which appears to have been reached, is the most 
determinate element. When the physician reaches his patient 
she may be experiencing the very first dilating pains, or she 
may alreadj^ have progressed into the second or propulsive part 
of labor. In the latter instance, an examination cannot be made 
too soon, while in the former, there would be no .occasion for 
haste. Unluckily, the existence of these various conditions can- 
not in every case be determined. It is possible, as a rule, to 
distinguish between the first and second stages of labor by ex- 
ternal signs, as, for example, the peculiar pains of each; but it 
does not follow that there is no urgency for an examination be- 
cause the os is not supposed to be wide open, nor that there is 
an inexorable and immediate demand for it because real propul- 
sion has begun. The best counsel is, not to be so precipitate in 
necessary investigations as to shock the patient, or betray trep- 
idation ; and on the contrary, not to permit undue caution or 
constraint to carry one to the opposite extreme; but to act delib- 
erately and discriminately, keeping in mind the desirability of 
recognizing the important features of every case through a thor- 
ough vaginal examination, as early in labor as practicable. 

The finger is generally recommended to be introduced during 
a pain; but it is far preferable to do so in the interval between 
pains, and to continue the examination during a contraction. 

The patient need not be restricted to any one position for the 
purpose of examination. Women are extremely restless during 
labor, and in frequent changes seek relief. They assume all 
sorts of postures, and resort to all kinds of expedients, and one 
must deal in an accommodating way. Let the woman remain 
undisturbed by any considerable change, and she will evince less 
aversion to the necessary touch. The allusion is now to cases as 
they are ordinarily met. When for operative purposes, an ab- 
solute diagnosis of the exact presentation and position, and the 
condition of the parturient canal in obscure cases, becomes 
essential, the position most favorable for differential distinctions 
should be prescribed. This is generally upon the back, near 
the edge of the bed, so as to permit the use, with equal f acil- 



302 



THE MANAGEMENT OF LABOR. 



ity, of either hand. Sometimes the os uteri and presenting 
part are brought nearer the ringers when the decubitus is lateral. 

Cursory examinations are of little value. In the practice of 
obstetrics, as well as in all other affairs, "what is worth doing at 
all, is worth doing well." None of us possess supernatural 
powers, and therefore ought not to assume celestial airs. It 
takes time to make a thorough exploration. 

Nothing is more annoying to a woman of delicate sense than 
a bungling attempt to pass the finger. A hint worth remember- 
ing is that the vaginal orifice lies but slightly in front of a line 
from one ischial tuberosity to the other. Whether the woman 
lie on her side, or on her back, the hand may be passed in a 
careless manner against the tuber to locate it, and thus ensure 
proper direction to the fingers. 

Fig 121. 




The vaginal touch. 



The points to be observed in a careful examination are the 
conditions of the vulva, bladder, rectum and vagina; the size 
and relative state of the os and cervix uteri; the general loca- 
tion of the presenting part, its character and position; the con- 
dition of the foetal membranes, and the general capacity of the 
pelvis, at the brim, in the cavity, and at the outlet. 



EXTEKNAL EXAMINATION. 303 

Frequent examinations should be avoided as they tend to 
irritate the vulva, and cause the woman, if sensitive, unnecessary 
suffering. Yet, no matter how painful they may be, they should 
be made often enough to acquaint the physician with the pro- 
gress being made. A single finger may answer, but two fingers 
should, as a rule, be employed. In every instance they should 
be smeared with some bland lubricant before introduction. 

External Examination. — Examination of the abdomen by 
palpation should not be omitted, and if there be a serious doubt 
concerning the presentation, single pregnancy, or foetal life, 
ausculation should be practiced. A superficial manual examin- 
ation of the abdomen, rapidly made under the clothes, is a 
common practice; but it is advisable to go further and make a 
systematic, scientific and accurate manipulation, by which we 
may ascertain the existence of pregnancy, the foetal position, 
presentation, approximate size and general condition, and the 
relations of the uterus. Concurring heartily in what Hoist says 
on the subject of bimanual examinations,* that " a detailed dis- 
cussion of this method of examination is necessary to the com- 
pleteness of a text book," we have elsewhere considered the 
subject at some length. 

Has Labor Begun ? — As a rule when the physician is called, 
there is no doubt as to the commencement of the delivery. 
Often he is not summoned till the middle of the process, and 
upon examination finds the os uteri open, the liquor amnii dis- 
charged, and the head of the foetus approximating the outlet. 
In other cases, however, the existence of what have been de- 
scribed as false labor pains, leads the woman to believe that 
parturition has made some progress, when in reality it has not 
begun. Careful attention to a few clinical hints will confer the 
knowledge and acumen necessary to differentiate the real signs 
of labor. With the finger, or fingers, in the vagina, observe 
during a pain, whether there is any descent of the presenting 
part, or distension of the bag of waters, and other symptoms of 
forcible uterine contractions. Observe further, as the pains 
come and go, whether there is progressive uterine dilatation. 
Mere openness of the os uteri is no affirmative evidence. There 

* Beitriijye zur Gyn, it. Gel)., 1867. p. 2. 



304 THE MANAGEMENT OF LABOE. 

is a difference between real dilatation of the os, such as comes 
from incipient labor, and an open state of the part. For weeks 
prior to delivery there is sometimes expansion to the extent of a 
quarter of a dollar, or even more. An increasing expansion of 
the os uteri denotes the existence of real parturition. The three 
decisive indications of labor are then, 1. The advance and re- 
treat of the presenting part; 2. The tension and relaxation of 
the membrane; and, 3. Above all, the progressive expansion of 
the uterus. 

Other, less decisive, indications of labor are an open and re- 
laxed state of the vulva, accompanied with a more or less free 
flow of mucus, or mucus and blood; also rhythmical pains return- 
ing every ten, fifteen, twenty or thirty minutes. 

False Labor-pains. — Women, as they approach the close 
of utero-gestation, often suffer with pains which simulate, in a 
measure, those of labor. Believing that real travail has begun, 
they summon the physician to their bed-side, to whose annoy- 
ance an investigation develops no substantial evidence of incipi- 
ent parturition. "False alarms" of this kind are by no 
means infrequent, and are sometimes repeated by the same 
woman. 

The symptoms of false labor-pains vary to correspond with 
the causes whereon they depend. The pain is often located in 
the umbilical region, and is clearly referable to the enlarged 
uterus. The ovarian region is sometimes its seat, and again it 
is felt in the hypogastrium, in which case it most closely simu- 
lates the pains of real labor. Finally, it is occasionally felt most 
s-everely in the lumbo-sacral articulation, and extends down- 
wards into the thighs. 

False labor-pains are, as a rule, continuous, but still may pre- 
sent exacerbations. In some instances they are intermittent, 
but irregular in recurrence, while occasionally they come and 
go with the rhythmus of true pains. 

Causes. — Spurious labor-pains owe their origin to a variety of 
causes. Undue distension of the uterus and abdomen may be 
set down as one of them. This may operate in a two-fold man- 
ner. 1. The very distension may create a bearing, tensive feel- 
ing in the pelvic region, especially in the latter half of the ninth 
month, when there is usually more or less subsidence of the or- 



FALSE LABOE PAINS. 30'5 

gan; 2. The normal contractions of the uterus* which regu- 
larly recur throughout the greater part of pregnancy, may 
become painful as a result of the great tissue strain which 
exists. 

Apart from unusual distension, there is, in the few days which 
precede labor, great pressure downwards of the gravid organ, 
which is capable of creating not only vesical and rectal irrita- 
tion, but a certain amount of real pain. 

Women of delicate organization, and those whose strength 
has been impaired by disease, are liable to suffer from neuralgia 
affecting the pelvic and abdominal viscera. Pains of this char- 
acter are often intense, and sometimes observe a degree of regu- 
larity in recurrence. 

In some cases, what are termed false labor-pains may be due 
to rheumatism, though probably it is not a common cause. The 
uterus being rendered exquisitely sensitive by its rheumatic 01! 
rheumatoid state, cannot painlessly undergo the distension, the 
pressure, and the slight contraction, to which it is physiolog- 
ically subject. 

Yery likely false labor-pains are frequently excited by reflex 
causes. Irritation exists at some point, — commonly the stomach 
or bowels, — and is reflected to the uterine region, giving rise to 
suffering resembling that of incipient parturition. 

Diagnosis. — The physician ought to be able to discriminate 
with exactitude between the genuine and the spurious, as he 
may thereby protect his professional credit, and save his patient 
an unnecessary amount of distress. Reputable and generally 
competent physicians, have been victims of error in such cases. 
A correct diagnosis is not always made with facility. Single 
symptoms are not decisive: a sound opinion must rest on the 
totality of signs. 

Perspicuity in differentiation between spurious and genuine 
labor-pains is best attainable by a close comparison like that 
which follows: 

* Bkaxton Hicks, "Obst. Trans." v. 13. 



306 



THE MANAGEMENT OF LABOR. 



TRUE. 

1. Most frequently felt in lumbo- 
sacral and hypogastric regions. 



2. Pains rarely constant. 

3. Pains always recur with regu- 
larity. 

4. Pains quite uniform in dura- 
tion. 

5. Pains at first far apart, and fee- 
ble, gradually becoming more fre- 
quent and severe. 

6. Pains generally preceded or ac- 
companied by a mucous, or muco- 
sanguineolent discharge from the 
vagina. 

7. The internal os is found to have 
yielded partially, or fully, and the 
cervical body to have disappeared. 

8. The uterus during a pain con- 
tracts with force, and the membranes 
bulge. 

9. The os uteri is found to be di- 
lating. 

Treatment — If the pains are severe, the woman ought to be 
placed in the recumbent posture, in a quiet room, and every an- 
noyance attentively removed. Search may then be made to 
ascertain if the pain is not reflected from some distant point, and 
if such a cause is found, it must, if possible, be removed. 

Local treatment will afford much relief, especially in rheuma- 
tic and neuralgic cases. Hamamelis or warm spirits may be 
freely applied to the abdomen. Unctuous applications will 
greatly relieve the feeling of over-distension, and consequent 
suffering. 

When the pains observe a decided periodicity, like those of 
labor, caulophyllum in a low potency is very effectual in many 

*Playfair, "System of Midwifery," p. 142. "After the uterus is suffi- 
ciently large to be felt by palpation, if the hand be placed over it, and be grasp- 
ed without using any friction or pressure, it will be observed to distinctly 
harden in a manner that is quite characteristic." 



FALSE. 
1. Sometimes felt in lumbo-sacral 
and hypogastric regions; occasion- 
ally in inguinal, but oftenest in um- 
bilical region. 

2. Pains often constant, sometimes 
remittent, but rarely intermittent. 

3. Pains generally irregular. 

4. Pains generally very unequal 
in duration, 

5. Pains continuous, remittent, or 
intermittent with short intervals, 
their intensity observing no regular 
increase. 

6. Pains occasionally accompanied 
by a mucous discharge from the vag- 
ina. 

7. The internal os sometimes found 
closed, and the cervix distinct. 

8. There may be uterine contrac- 
tion,* but it is not forcible, and the 
membranes, if they can be felt, are 
but slightly, or not at all, affected. 

9. The os is not dilating, though 
occasionally it is somewhat patulous. 



patient's bed and dress. 307 

cases. Some physicians regard it as a real specific. When 
there is spasmodic pain, or when the woman suffers in the ova- 
rian region, especially at night, and is restless and uneasy, Pul- 
satilla should be given. Actcea racemosa is peculiarly service- 
able in rheumatic or rheumatoid conditions. Belladonna, and 
its active principle atropia, are especially suited to the pains 
when of a neuralgic character. Nux moschata: spasmodic, 
irregular pains ; the patient has drowsy, faint spells. 

Nux vomica may be required when the pains seem to depend 
on gastric irritation. 

Arsenicum album: when there is gastric irritation and thirst: 
the pains are sharp and distressing. 

The Patient's Bed and Dress. — These are matters with 
which the physician generally has little to do, as they properly 
belong to the nurse or other female attendants. It is wise, how- 
ever, for the physician to be prepared to supervise them, when 
in emergencies, he is appealed to. The bed should not be very 
soft; — the best is a good hair mattrass upon a tick filled with 
straw or husks. A soft rubber, or oil cloth, should be laid over 
the mattrass, and a sheet spread upon it. A folded sheet should 
also be placed under the woman's hips. Instead of spreading out 
the sheet, it may be pinned about the hips, her chemise and 
nightdress having been rolled up, for protection. During labor 
the amount of covering may be regulated to suit the patient's 
wishes, unwise exposure being avoided. 

The lying-in chamber should be as large and airy as the house 
affords, and provided with good facilities for heating, if the labor 
occur in a cool season. 

Position of the Woman. — If the room is warm, there is no 
valid objection to the patient walking or sitting as her inclina- 
tion may suggest, in the early part of labor; but this should 
not be permitted after the second stage is fairly inaugurated. 
She ought then to be confined to her bed. When the presenting 
part has descended low into the pelvic cavity, and the pains are 
strong, on no account should she be permitted to rise. The com- 
pression exerted by the head, or other presenting part, may 
create a tenesmus of both bladder and rectum, and frantic re- 
quests be made for the privilege of using the chamber vessel. 
This, however, should 'not be permitted, for fear of a sudden 



308 THE MANAGEMENT OF LABOB. 

termination of the expulsive act, while the woman occupies an 
attitude unsuitable for proper protection of mother and child. 

The Physician's Attendance During the First Stage.— 

During the first stage of labor the physician ought not to be in 
constant and close attendance, as such attention would raise too 
high the woman's expectations of speedy delivery. The physician 
himself will find frequent, and somewhat prolonged, absence 
from the room a grateful relief from the oft-repeated query, of 
both the patient and her friends, regarding the duration of labor. 
To give non-committal, and yet satisfactory answers, is no easy 
task. His absence, too, will give the woman time and opportu- 
nity to use the chamber- vessel, or visit the closet, a thing which 
she should be encouraged to often do during this stage. If at 
any time there should be evidence of much urinary accumula- 
tion, with inability to empty the bladder in a natural way, the 
catheter ought to be employed. 

Bearing Down. — Women are generally encouraged by the 
nurse, and other bystanders, to bear down with force whenever 
a pain returns ; but in the first stage of labor this should be 
utterly discouraged. The practice is not only useless, but harm- 
ful. In the second stage only can decided aid be, derived from 
abdominal efforts, and earlier exertion tends to exhaust the 
patient's strength without adequate compensation. 

Treatment of the Membranes. — Upon making a vaginal ex- 
amination after labor has fairly begun, there is often, but not 
always, to be felt protruding into the os uteri during a pain, a 
tense disk of membranes, termed the bag of waters, or the bag 
of membranes. It is the practice of some to break this bag, 
and allow the liquor amnii to escape, early in labor, under the 
belief that progress is thereby accelerated; but the most ap- 
proved treatment is to refrain from so doing until full dilatation 
of the os has been accomplished. The latter conduct is generally 
recommended on the theory that the bag of waters, by the 
hydrostatic force which it exerts, aids very materially in the 
process of dilatation. It is found, however, that, in a large per- 
centage of cases, there is no distinct bag of waters at the os 
uteri, and yet dilatation proceeds in just as satisfactory a man- 
ner. Again, in certain cases wherein the phenomena of the first 
stage are slowly and tediously manifested, rupture of the mem- 



THE SECOND STAGE. 309 

branes will often greatly accelerate the natural processes. Still, 
we will probably do well to adhere, as a practice, to the old rule, 
and refrain from rupturing the membranes until the stage of 
uterine dilatation has been completed. If rupture of the mem- 
branes is not easily accomplished with the finger, the effort being 
made during a pain, a straightened hair-pin, a probe, or a stiff 
catheter may be carefully used. 

The Second Stage. — Thus far we have treated mainly of the 
duties of the accoucheur during the first stage of labor. But 
with complete dilatation of the os uteri the first stage closes, 
and is succeeded by the second, or propulsive, stage. The pre- 
cise moment of complete dilatation is not always easily recog- 
nized. Indeed, there appears to be some dissonance of opinion 
with reference to what constitutes full dilatation. We are left 
to infer from most descriptions that complete expansion is not 
accomplished until the os has passed out of reach of the exam- 
ining finger. What we have to say here with reference to the 
management of the second stage of labor is fully applicable, 
however, to a period which somewhat precedes entire retraction 
of the os uteri. For practical purposes, then, we may regard 
the first stage of labor fairly closed when the os is widely ex- 
panded, and the presenting part, proper, and not alone the caput 
succedaneum, protrudes, during a pain, to a certain extent, 
through the os uteri. 

Encourage Bearing Efforts. — The phenomena of the second 
stage are distinct and peculiar. The woman is now disposed to 
bring into action her abdominal muscles, and with each severe 
pain to make a strong bearing effort. This action, unless vehe- 
ment beyond measure, ought to be encouraged, and every facility 
afforded for its proper direction and utilization. While she 
occupies the dorsal position, the physician may sit beside the 
bed, or upon it, and hold one hand of his patient, while some 
one on the opposite side holds the other. The feet may be braced 
against the foot-board directly, or through the intervention of a 
stool, box, or chair; or, what will answer as well, the woman's 
knees may press against the shoulders of her assistants. Now, 
by encouraging her to close her mouth, to hold her breath, and 
to pull and bear down, very effective work may be done. When 
lying on her side, both hands may be held by an assistant, while 
her knees rest against his or her chest. Such counter-traction 



310 THE MANAGEMENT OF LABOK. 

requires the services of a strong person. Between pains the 
woman should be permitted to take perfect rest. If descent 
proceeds rapidly, the fingers of the accoucheur should be kept 
within the vagina, and the case carefully watched; but if slow 
progress is made, an occasional examination only, is for a time, 
required. 

The pains of the second stage are in some respects more sat- 
isfactory to the patient, than those of the first stage, inasmuch 
as they appear to be more effective; but the real suffering ex- 
perienced in this part of labor is far more intense. The woman 
becomes restless and impatient, and makes frequent inquiry as 
to how soon labor will terminate, at the same time declaring 
that she can endure the suffering no longer. Great tact is here 
required to maintain the patient's courage and confidence. The 
manifestation of the slightest perturbation by the physician, is 
liable to create a panic among the patient and her friends. Few 
words, fitly chosen, spoken with evident composure, are far bet- 
ter than long explanations, or much talk on any pretext whatever. 

The Use of Anaesthetics. — The general subject of anaes- 
thetics during labor will elsewhere be discussed, but we may 
here take occasion to say that, in the latter part of the propul- 
sive stage, when the pains become almost unbearable, there is 
no well-founded objection to be raised against the moderate use 
of chloroform. A few drops may be poured on a handkerchief, 
and when a pain is due, the woman may take a few inhalations, 
with the effect to somewhat benumb the sensibilities without 
producing narcotism. Such administration of a good article of 
chloroform is almost wholly devoid of danger, and may be con- 
tinued for several hours, if needed. A little instruction given 
the nurse will enable her to use the anaesthetic, to the ex- 
tent mentioned, with safety. The intensity of suffering en- 
dured by women in labor varies so considerably that chloroform 
should not be resorted to indiscriminately; but let it be given in 
those cases only wherein there is a strong demand for its sooth- 
ing aid. 

Indications for Interference. — So long as there is progress 
being made, we should abstain from interference. If the pains 
slacken, or if delay of the head in the pelvic cavity arises from 
any other cause, we should not allow the duration of the second 



USE OF THE CATHETER. 311 

stage to exceed the physiological limits. A satisfactory defini- 
tion of what is implied by the phrase "physiological limits" 
cannot easily be given, since its boundaries are not invariable, 
and require to be set in each individual case. It should be re- 
membered that pressure of the head upon the soft tissues of the 
pelvic cavity, leads, when prolonged, to pathological changes in 
the tissues of the canal and outlet. It is a wise rule of practice 
not to permit the head of a relatively large child to remain sta- 
tionary in the pelvic cavity for a period in excess of two hours. 
But before resorting to instrumental delivery, the aid of other 
means should be invoked. 

Feeble pains are sometimes intensified by changing the 
woman's position, as from the back to the side, or vice versa. 
Firmer flexion of the foetal head is sometimes thereby effected. 
When that part has descended to the perineum, expulsive action 
may be excited by kneading the abdomen, or by pressing upon 
the fundus uteri. 

Use of the Catheter. — There is sometimes considerable dis- 
tension of the bladder during the second stage, accompanied 
with utter inability to urinate. This distressing condition must 
at once be removed by means of the catheter. The use of the 
instrument is sometimes attended with considerable difficulty, 
owing to the pressure of the head against the neck of the blad- 
der, and a change in the direction of the urethra arising from 
excessive compression and partial prolapse of the anterior va- 
ginal tissues. On these accounts the best instrument for use is 
the soft rubber catheter of medium size. 

Incarceration of the Anterior Lip of the Os Uteri. — As 

the head descends in the pelvis, the anterior lip of the os uteri 
is sometimes caught and held between the head and the pubis, 
and may thereby become a manifest impediment to the progress 
of labor. Unless there is excessive tumefaction of the part, in- 
terference is seldom required. Rigby declares all attempts to 
push it above the pelvic brim not only futile, but decidedly ob- 
jectionable, since inflammation is liable to be set up. This dic- 
tum is not accepted by all. "Any attempt," says Leishman,* 
"rudely or forcibly, to push up the anterior lip, even when it 

* " System of Midwifery," Am. Ed., 1873, p. 269. 



312 THE MANAGEMENT OF LABOE. 

exists as a manifest impediment, should certainly be avoided; 
but we are bound to add that, in many cases, it may be pushed 
beyond the head with perfect safety, and in this way the im- 
pediment to delivery may be at once obviated." The attempt 
should be made in an interval between pains, and the part sus- 
tained until the recurrence of another contraction serves to 
maintain it in a situation beyond the reach of pressure. 

Support of the Perineum. — One of the most delicate tasks 
which the physician is called upon to perform during labor is to 
so regulate the exit of the head as to prevent perineal lacera- 
tion. The means adopted to prevent laceration, prior to Smel- 
lie's day, consisted mainly in the use of emollents and lubri- 
cants. He advised dilatation of the vulvar opening. Puzos 
advocated the use of both lubricants and dilatation. In 1781, 
Professor Hamilton, of Edinburgh, recommended the use of lu- 
bricants, and external perineal support, from the moment when 
the structure began to bulge until full expulsion of the child. 
From that time to the present, most writers on obstetrics have 
recommended some form of support for the perineum. A few, 
for example, Leishman,* advise against all firm external sup- 
port, as not only needless, but in some cases absolutely injuri- 
ous. He accepts Tyler Smith's theory, that, by external sup- 
port, the uterus is excited, through reflex action, to i greater 
energy at the very time when a contrary effect is sought. " The 
practitioner, however," says Leishman, "who never puts his 
hand to the perineum, will, we firmly believe, have fewer cases 
of ruptured perineum in his practice than he who admits sup- 
port in any form as applicable to every case of labor." * * * 
" We do not think, in reference to this subject, that we take an 
exaggerated view of the case in looking upon it as a relic of 
'meddlesome midwifery,' in which we presume, by irrational 
and bungling interference, to dictate to nature." He says, also: 
" And be it remembered always, that, do what we may, rupture 
of the perineum will, in a certain proportion of cases, as is ad- 
mitted by every one, occur." 

Kitgen f advises pressure of the finger tips upon the pelvic 
floor behind the anus, close to the extremity of the coccyx. 

* " System of Midwifery," Am. Ed., 1873, p. 271. 

f Olshausejst, "Ueber Dammverletzung und Dammsclratz," Volkmann's 
"Summlung." No. 41. p. 369. 



PERINEAL PROTECTION. 313 

Rectal expression is receiving hearty support from a number. 
This is effected by passing two fingers into the rectum toward 
the close of the second stage of labor, and hooking them into 
the mouth, or under the chin of the child, through the thin sep- 
tum between the vagina and rectum. By carefully operating, 
the head can thus be rotated and extended between pains, and 
delivery in some cases effected. 

Fig. 122. 




Method of supporting the perineum. 

Dr. Goodell * advises that the fingers be hooked into the anus, 
and the perineum be drawn forward, so as to remove the strain 
from the imperiled posterior vulvar commissure, and at the 
same time promote elasticity of the tissues. 

Fashenderf would have us practice a very novel and effective 
procedure. The woman is placed on her left side, and the ope- 
rator, standing behind her, seizes the foetal head between the 
index and middle fingers of the right hand at the occiput, and 
pushes the thumb into the rectum as far as possible. This gives 
him control of the head, the rectal wall offering but little resist- 
ance. In the interval between pains the thumb can be made to 
press the head forward and outward, without injury to the tis- 
sues. 

* " Am. Jour, of the Med. Sci.," Jan'y 1871. 

t Ztschr. f. Geburtsh, und Gynaek," Bd. ii, H. 1, p. 58. 



314 THE MANAGEMENT OE LABOE. 

In certain cases, especially primiparae, the head, instead of 
being deflected well forward, under the pubic arch, from the 
resistance offered by the perineum, presses directly upon this 
body with such force as to threaten central rupture. When 
this condition is observed, direct support to the perineum by 
the whole hand must be given, in an upward and forward direc- 
tion, so as to carry the occiput as closely as possible under the 
pubic arch, and at the same time establish and maintain firm 
flexion of the head. 

The accoucheur should not limit himself to the practice of 
a single mode of perineal support, — or, more properly,— perineal 
protection. The form of treatment suited to one case will not 
be the best for all cases, nor should we discard the more common 
methods of firm pressure in an upward and forward direction, 
under the impression that reflex uterine action will thereby be 
excited. From careful observations, frequently made, we are thor- 
oughly convinced that, practiced with an aim to carry the head 
well under the pubic arch, and maintain firm flexion, good results 
will follow. 

The free application of emollients and lubricants to the peri- 
neum, internally and externally, is an important part of treatment. 
For this purpose warm oil, or cosmoline, are to be preferred. 

Proper management of this stage of labor includes close 
attention throughout, to the condition of the perineum, and the 
prevention, by manual resistance, of sudden and forcible expul- 
sion of the head. If the conditions are such as to put but little 
strain on the vulvar opening, energetic measures for protection 
will not be required. The physician ought in every case to be 
prepared to afford the most suitable form of relief whenever the 
emergency may present. 

Episiotomy. — But, we inquire, can anything be done to pre- 
serve from serious injury a perineum which, by reason of an 
anomaly in construction, or which, through want of relative 
proportion between the dimensions of the foetus and vulva, is 
very certain to suffer laceration? In 1836 Yon Ritgen published 
an article * in which he recommended seven small incisions on 
each side of the vaginal orifice, to be made at the moment o£ 
greatest distension. No incision was to extend more than a line 

*"Neue Zeitschrift fur GeTrartskunde," iii Band. 



EPISIOTOMY. 315 

in depth. By this means he claimed that an increased vulvar 
circumference of two inches could be gained. The depth and 
character of the incisions have been changed by others, and, as 
we believe, the character of the operation improved. Attention 
has been directed to the fact observed by every attentive prac- 
titioner, that the chief resistance encountered by the head is not 
at the thin border of the vulva, but at a narrow ring situated 
half an inch above, represented posteriorly by the fourchette, 
and composed mainly of the constrictor cunni, the transversi 
perinsei, and sometimes of the levator ani muscles. It has been 
accordingly recommended that the incisions be made through 
these rigid fibres, by means of a blunt-pointed bistoury, or a 
pair of angular scissors. We are told that, so far as practicable, 
the incisions should be confined to the vagina, and should not 
exceed three-quarters of an inch in length. In cases where the 
head is about to be expelled, and firm pressure already exists, 
the bistoury may be carefully introduced, upon its side, between 
it and the vagina, half an inch in front of the commissure, and 
the section made from within outward. The external skin 
should not be included, and it may be protected by drawing it 
back before cutting. 

In this connection it should be remembered that serious per- 
ineal rupture is nearly always along the course of the raphe, 
owing to the relative weakness of the part, and the existence of 
a commissure. 

The increased danger of septicaemia has been urged against 
the operation, but the objection is void of much force. The 
choice is between several slight clean incisions, and one gaping 
rupture. It may be said for the incisions, that they are situa- 
ted laterally, are shallow, and together do not present a greater 
area of absorbing surface than the central rupture which follows 
the expectant plan. The latter, too, owing to its location, is 
more exposed to the discharges which carry most of the noxious 
germs, and from its depth, as observed by Dr. Fordyce Barker, 
permits the lochia to approach " an abundance of blood-vessels, 
and chains of lymphatic glands." 

By this operation, not only is the danger of complete lacera- 
tion of the perineum prevented, but, owing to their eligible po- 
sition, the wounds generally repair spontaneously, while in case 
of rupture along the raphe, retraction of the transversi perinsei 



316 THE MANAGEMENT OF LABOR. 

muscles causes the wound to gape, and prevents immediate 
union. 

Laceration of the perineum often takes place during passage 
of the shoulders. Some authors insist that the shoulders cause 
the accident of tener than the head. While this is probably an 
error, the fact that they frequently give rise to the accident, 
should lead the practitioner to adopt every precaution in ex- 
tracting them. Descent of the hand by the side of the neck, 
and the subsequent pressure of the elbow as it passes the vulva 
with a snap, are the prolific cause of the accident. Attention 
to the mechanism of extraction will here afford greater protec- 
tion than perineal support, however well applied. 

Frequency of Perineal Laceration. — According to Schroe- 
der's experience, the frenulum or fourchette is ruptured in 
sixty-one primiparse out of the hundred. More extensive lacer- 
ation takes place in thirty-four and one-half per cent, of first 
labors, and nine per cent, of others. 

Olshausen found the perineum ruptured in 21.1 per cent, of 
prirniparge, and 4.7 per cent, of multiparas 

Winkel in 11.5 per cent, of all cases. 

Hildebrandt in 7.2 per cent, of all cases. 

Yon Hecker in 36.6 per cent, of all cases. 

Extent of Rupture. — There are various degrees and varie- 
ties of perineal rupture. A mere margin, involving only the 
fourchette, may be torn, or there may be laceration of the en- 
tire perineal body, so as to make the rectum and vagina one 
horrible hiatus. Between these extremes are various degrees. 
Perineal rupture has been divided into classes according to va- 
riety and extent of the tear. The most simple classification is 
that which separates cases into complete and incomplete rup- 
tures. When the laceration extends through the sphincter 
ani into the rectum, it is termed complete, while anything short 
of that is called incomplete. This will answer general purposes, 
and where it is desirable to be more explicit, these classes may 
be made to embrace the following degrees of destruction, as 
named by Dr. Thomas : 

Superficial rupture of the fourchette and perineum, not in- 
volving the sphincters.* 

* "When the anterior edge of the perineum alone is referred to, as for in- 
stance, in a laceration not amounting to half an inch in linear extent, it is 
called the fourchette." — Dk. Matthews Duncan. 






DELIVERY OF THE SHOULDERS. 317 

Rupture to the sphincter ani. 
Kupture through the sphincter ani. 

Rupture through the sphincter ani, and involving the recto- 
vaginal septum. 

Delivery of the Shoulders.— When the head has finally 
cleared the vulva, the secretions should be wiped from the 
nose and mouth of the foetus, and examination then made to as- 
certain whether the umbilical cord is about the neck. If the 
cord is found, it should be loosened by drawing carefully upon 
it, until it can be slipped over the head, or, failing in this, dur- 
ing extraction it should be passed over the foetal shoulders, so 
as to avoid strangulation of the child, and unnecessary and 
harmful traction. If the cord is evidently too short to admit of 
such treatment, or if there are several turns about the neck, two 
ligatures may be hastily applied, and the cord severed between 
them. After so doing, however, extraction must not be delayed, 
or the foetus will perish. 

In most cases the shoulders are expelled without aid. But, 
should there be delay, slight traction may be made on the head, 
while an assistant presses with some force on the fundus uteri. 
When the movement of expulsion begins, the operator's hand 
should be placed at the posterior vulvar commissure, and the 
shoulder raised with some force, as a protection to the peri- 
neum. As the arm, or elbow, of that side passes, special pro- 
tective effort should be made. 

As soon as the child is expelled, the little finger of the ope- 
rator should be passed into the throat, and the face turned for- 
ward, so as to clear the part of mucus. 

Treatment of the Cord. — It is observed that when, from any 
cause, the umbilical cord is torn in twain, as sometimes acci- 
dentally happens, there is little or no hemorrhage. It has been 
found also that, in many cases, the cord may be cut with scis- 
sors, and no ligature applied, without the occurrence of any ex- 
tensive blood-loss. These, and other considerations, have led 
some to recommend and practice non-ligation of the cord, as an 
ordinary mode of treatment. We have given the practice a 
pretty thorough test in Hahnemann Hospital, and have found 
that, if we will but await the cessation of pulsation in the cord, 
it may be cut without fear of hemorrhage, and the case do well. 



318 



THE MANAGEMENT OF LABOR. 



It is probably a mode of treatment which will eventually be- 
come common, since it appears to possess some advantages, but 
Fig. 123. the rule of practice is yet strongly in favor 

of the ligature. Some practitioners lay 
much stress on the quality and texture of 
the material used for ligatures, but a string 
of almost any firm material may be em- 
ployed. The knot should be about an inch 
and a half t from the umbilicus, and tightly 
drawn, so as to prevent the possibility of 
hemorrhage. A ligature loosely applied 
is worse than none. In tightening it, the 
two thumbs should be placed back to back, 
and the knot made firm by turning them 
inwards. If direct traction is made, break- 
ing of the string may give rise to umbilical 
injury from the severe and sudden strain 
which is likely to be given. A second lig- 
ature should then be applied on the side to- 
ward the placenta, and the cord be severed 
Showing Ligatures of between. The last ligature is applied 
the Umbilical Cord. chiefly for the purpose of protecting the 

bed and clothing from unnecessary soiling. In twin pregnancy 
it is employed as a preventive of possible blood-loss through 
vascular relations between the placenta. The form of knot to 

be used is the reef, or square knot, as 
shown in the accompanying figure. In 
such a knot the ends of the ligature lie 
across the umbilical cord, instead of 
parallel to it, as in the ordinary knot. 

Early and Late Ligation.— The most 
The Square Kuot. desirable moment at which to tie the 

cord is a matter worthy consideration. 
The common practice is to ligate it immediately after foetal expul- 
sion. The errors of such a practice had been pointed out by 
several, when Budin, in 1875, at the suggestion of Dr. Tar- 
nier, made the following observations . In one series of experi- 
ments the cord was tied immediately after birth of the child, 
and the blood which flowed from the placental end was measured; 




Fig. 124. 




EARLY AND LATE LIGATION. 319 

in the other series, the quantity of blood was likewise deter- 
mined in cases where the cord was not tied until after the lapse 
of several minutes. By a comparison of the results thus ob- 
tained, he found that the average amount of placental blood was 
three ounces greater in the first than in the second series of ex- 
periments.* Melcker estimated the entire quantity of blood in 
the infant at one-nineteenth the weight of the body, which in a 
child weighing seven pounds, would amount to six ounces. In 
1877 Schucking in similar experiments first weighed the child 
at birth, and then observing the changes which took place up to 
the moment of cessation of the placental circulation, found that 
it gained from one to three ounces in weight by the delay. An 
allowance should also be made for the portion which escapes 
observation in the interval before the weight is taken. 

What brings about the transfer of the blood from the pla- 
centa to the child is an unsettled question. Budin believes that 
with the first inspiration, the increased flow of blood to the 
lungs sets up a negative pressure in the vessels of the systemic 
circulation, so that a suction force is exerted upon the placental 
blood, which condition is maintained until the equilibrium is 
again established. To tie the cord at once, therefore, prevents 
the adequate supply of the demands created by functional pul- 
monary activity. Schuecking f takes a different view, maintain- 
ing that, after the first breath, thoracic aspiration ceases to 
constitute an active energy, and that the main force which ope- 
rates to cause a transfer of the blood, is the compression exerted 
by the retraction, and, at intervals, by the contractions of the 
uterus. 

From clinical observation and experimental research, the just 
conclusion is that there is an element of truth in both these 
theories concerning the cause of the phenomenon in question. 

Several observers have shown that the loss of weight which 
occurs in the first few days after birth is less, and the period of 
loss is shorter, when the ligature is not applied until pulsation 
in the cord has ceased, and the children are more likely to be 
red, vigorous, and active. This may also explain some of the 

* Budin. " A quel moment doit-on ope'rer la ligature du cordon ombilical." 
" Publication du Progres Me*dicale " 1876. 
f " Zur Physiologie der Nchgeburtsperiode," " Berl. Klin. Woch." Nos. 1 

and 2, 1877, 



320 THE MANAGEMENT OP LABOK. 

advantages claimed for non-ligation of the funis, inasmuch as 
pulsation generally ceases before the scissors are used. As soon 
as pulsation does cease, the cord ought to be cut, or ligatured. 

Dr. N. Andrejew* gives the results of his observations in 
ninety-three full-term children of healthy parentage, and nursed 
by the mothers. It was shown that the children in whom the 
cord was tied early (one to one and a half minutes after birth,) 
suffered less physiological loss of weight, and more readily in- 
creased in weight, than those in whom the cord was tied late — 
two minutes after the cessation of pulsation in it. The physio- 
logical time at which to ligature or cut the cord appears to be 
as stated, immediately upon cessation of the pulsation in it. 

The Third Stage. — After separation of the child it will be 
handed to the nurse, or some lady assistant, to be washed and 
dressed, while the physician attends to the duties of the third 
stage, which have reference now to promoting uterine contrac- 
tion, the prevention of hemorrhage, and the expulsion of the 
placenta. To remove the placenta, when it is not soon expelled 
by the natural efforts, the old method is to make traction on the 
cord, at first in the axis of the superior strait, and afterwards in 
the axis of the inferior strait. Such treatment, however, through 
the central insertion of the cord, generally inverts the placenta. 
This of itself could do no possible harm, but it has been claimed 
with a good show of reason, that such traction creates a certain 
amount of suction at the placental site, which is liable to pro- 
duce hemorrhage. It is claimed that inversion of the uterus has 
in a few instances been produced by a similar cause. 

Credos Method of Placental Expression. — To obviate this 
danger, a mode of placental delivery has been recommended by 
Credent and is now practiced by a large number of obstetricians, 
which consists in applying a vis a tergo, instead of the old vis a 
fronte. It is practiced by grasping the fundus uteri with the 
hand in such a way as to press well behind it, and then making 
firm pressure downwards and backwards in the axis of the su- 
perior strait. The result is not obtained alone by the manual 
force applied, but the uterus is stimulated to contract by the ab- 
dominal manipulation. 

* Jahrbch. fur Kindhlknde, xvii., 2. 

f Monatsschrift fur Geburtskude, xvi, 337. 



DELIVEBY OF THE PLACENTA. 



321 



Immediate efforts at expulsion are recommended by some,f 
but for the physiological reasons mentioned under the head of 
"Early and Late Ligation," delay is preferable. In any case it 
is best at first to apply light, and afterward stronger, friction to 
the fundus uteri, until an energetic contraction is established. 
The most approved way seems to be for the physician to place 
his hand over the fundus, exerting only sufficient pressure to 
maintain uterine contraction and guard against hemorrhage, 
moving the hand about from time to time in gentle friction, until 
uterine action is excited, when lie should make firm and equable 
pressure in a direction downward and backward, until extrusion, 
at least into the vagina, is effected. If the first strong effort is 
unsuccessful, it should be repeated during the succeeding uterine 
contraction. When delivery is completed in this way, the pla- 
centa is usually found non-inverted, as in those cases in which 
expulsion is effected by the natural efforts. 

Fig. 1:25. 




Showing Crede's method of delivering the placenta. 

The Combined Method of Placental Delivery.— Though 
Crede's mode of delivering the placenta seems simple and easy, 
many have in practice, found it extremely difficult. This is 
probably owing, in most instances, to deviations from the pre- 
scribed rules, while in others it has probably occurred mainly 
through fear to apply the necessary amount of pressure. The 



fSPIEGELBERG. ' Lelirhuch," p. 192. 



322 



THE MANAGEMENT OF LABOR. 



author has found much greater satisfaction in combining the 
two general modes of placenta delivery, namely, pressure on the 
fundus uteri, and traction on the cord. We believe this mode 
of treatment free from any serious objections, while it proves 
remarkably effective and easy. A short hold should be taken 
on the cord, within the vagina, so that traction can be made in 
a line approximating the axis of the brim, and with the disen- 
gaged hand simultaneous pressure is exerted on the fundus 
uteri. 

It will occasionally be found that 
occlusion of the cervix is complete, 
and the placenta cannot be brought 
away without first introducing two 
fingers and hooking down the margin 
of it, so as to admit a certain amount 
of air. 

Extraction of the placenta should 
be slowly effected, to avoid tearing 
the membranes. The latter are usu- 
ally left trailing in the vagina after 
birth of the placenta, and in order 
to secure their complete removal it is 
best to twist them into the form of 
a rope, and extract them with the ut- 
most care. After expulsion or extrac- 
tion of the placenta and membranes, 
the physician should see that the 
uterus remains well contracted. In 
most cases we find that organ firmly 
condensed in the hypogastrium, in a condition known as " can- 
non-ball contraction." 

Manual Compression of the Uterus. — Throughout the third 
stage of labor, and for a varying period thereafter, the hand of 
the physician, or some trusted assistant, should rest upon the 
fundus uteri, at the same time exerting some degree of pressure. 
If, after placental delivery, the organ manifests a decided 
tendency to relax, friction and kneading of the abdomen should 
be practiced, to excite uterine contraction. This sort of treat- 
ment should in no case be omitted, as its influence upon the 




Inversion of placenta 
traction on the cord. 



from 



POST-PAKTUM CARE OF THE WOMAN. 323 

third stage of labor, and the puerperal state, is decidedly salu- 
tary. 

After removal of the placenta, the perineum should be thor- 
oughly examined by means of the thumb in the vagina, and a fin- 
ger in the rectum. Tactile examination is more modest, and is 
fully as satisfactory as visual. 

Post-partum Care of the Woman. — The general condition 
of the woman, and the special state of the uterus, should be 
carefully watched for some time after delivery. First of all she 
should be warmly covered to prevent the occurrence of chilling. 
The manual attention given the uterine contraction, before men- 
tioned, should be maintained in simple cases for at least fifteen 
minutes after placental delivery. The pulse will also furnish a 
criterion from which to draw valuable conclusions. If it is 
found to be rapid, the case requires undivided attention so long 
as it thus continues, while if quiet and regular, little anxiety 
need be felt. The physician should in no case leave his patient 
within the first half hour after delivery ; and if hemorrhage has 
been threatened, he should stay much longer. 

The administration of arnica should be begun immediately, 
and, in the absence of more specific indications, ought to be 
continued hourly during the first twelve hours, or longer. 

When the hand is removed from the uterus, the nurse, and 
other assistants, should withdraw the soiled clothes, and make 
the patient as clean and comfortable as possible, without much 
disturbance. It is a good practice to have the nurse also wash 
out the vagina with a very gentle stream of carbolated warm 
water, the point of the tube being introduced into the vagina 
but a short distance. 

The Binder. — The use of the binder is a point in practice 
over which there has been much discussion. Some practition- 
ers of much repute believe that it is not only valueless, but posi- 
tively harmful, and utterly discountenance its use. Every care- 
ful observer, however, must admit that a certain amount of 
pressure is essential to the patient's perfect comfort. After 
labor women feel as though they " were falling to pieces," and 
the binder, if it does no more, certainly contributes greatly to 
their comfort. To completely fulfill the requirement, the binder 
must be properly applied. A narrow bandage will not keep its 
place, and is liable to do more harm than good. Its width will 



324 THE MANAGEMENT OF LABOR. 

vary somewhat in different cases, but the average should be 
about twelve inches, and it should cover the entire abdomen. 
To do this it must be brought well down over the hips. Almost 
any material will answer the purpose, but a strong piece of un- 
bleached muslin is preferable. By some, a pad, consisting of a 
large napkin, or small folded towel, is placed over the hypogas- 
trium. 

To make a neat and effective application of the binder is a 
thing not easily accomplished by the novice; and yet every phy- 
sician ought to possess the necessary skill. To properly place 
it under the woman's hips, requires the services of at least two. 
When this is done, the physician should hold the end nearer 
him between the thumb and fingers of the left hand, if he is 
standing to the right of his patient, and of the right hand if he 
stands on her left, while he draws the opposite end tightly over 
it, and applies the first pin in the side toward the vulva. Seven 
or eight pins should be used, and when fully applied, the binder 
should.be free from wrinkles. The woman's toilet is completed 
by placing a warm napkin at the vulva to receive the discharges. 
If now comfortable, and her pulse quiet, she may be left by 
the physician in the care of her nurse, who if not well ac- 
quainted with her duties should receive explicit instructions. 

Therapeutics.— In the course of normal labor there would 
seem to be but few occasions for the use of remedies; but un- 
pleasant symptoms are sometimes associated with the usual 
phenomena, and without being essential parts of the parturient 
action, are amenable to the suitable remedy. We therefore here 
append the following indications: 

Labor-Pains.— Inefficient, etc.— Violent and frequent, but 
inefficient, aconite. 

Too weak, not regular: cethusia. 

Violent, but inefficient: arnica. 

Tormenting, but useless, in the beginning of labor: caulophyl- 
lum. 

Short, irregular, spasmodic, patient very weak, no progress 
made: caul. 

Spasmodic and irregular: cocculus. 

Spasmodic: caust, ferrum, pulsatilla. 



THEEAPEUTICS OF LABOE. 325 

Spasmodic, cutting across from left to right, nausea, clutch- 
ing about the navel: ipecac. 

Spasmodic, painful, but ineffectual: platina. 

Spasmodic, they exhaust her, she is out of breath: stannum. 

Spasmodic and distressing, tearing down the legs: cham. 

Insufficient, violent backache, wants the back pressed, bearing 
down from the back into the pelvis: kali c. 

Distressing, but of little use, cutting pains across the abdo- 
men: phos. 

Ineffectual, of a tearing, distressing character, they do not 
seem to be properly located: actcea. 

Severe, but not effective, she weeps and laments : coffea. 

Weak, False, Deficient. — False, labor-like pains, sharp pains 
across abdomen: actcea, caul. 

Pains weak or ceasing, wants to change position often, feels 
bruised: arnica. 

Weak or ceasing, will not be covered, restless, skin cold, cam- 
phor, c. c. 

Deficient or absent; she has only slight periodical pressure 
on the sacrum, amniotic fluid gone, os uteri spasmodically closed'. 
belladonna. 

Weak or ceasing, with great debility, especially after violent 
disease, or great loss of fluids: carb. v. 

Pains become weak, flagging, from long-protracted labor, caus- 
ing exhaustion; patient thirsty, feverish: caul. 

Cease, from hemorrhage: china. 

Ceasing, with complaining loquacity: coffea. 

Weak, or accompanied with anguish; she desires to be rubbed: 
natrum m. 

False or weak, spasmodic, irregular, drowsy faint spells, with 
weak pains: nux m. 

Deficient, irregular, sluggish: Pulsatilla. 

Weak and ceasing: thuja. 

Deficient, with os soft, pliable, dilatable: ustilago. 

Suppressed, or too weak: secede. 

Cease, coma; retention of stool and urine — from fright: op mm. 

Strong. — Excessively severe : coffea, nux v. 

Too prolonged and powerful : secale. 

Effect on Patient.— Labor-pains make her desperate, she 



326 THE USE OF ANESTHETICS. 

would like to jump from the window, or dash herself down: 
arum try. 

During pain she must keep in constant motion, with weeping: 
lycopodium. 

Cause fainting: nux v., verat alb, puis. 

Cause urging to stool, or to urination: nux v. 

Excite suffocative or faint spells, must have the doors and 
windows open: Pulsatilla. 

Exhaust her; she faints on the least motion: verat a. 

Cause weeping and lamenting: coffea. 

Location and Course. — Pains principally in the back: caust. 

Pains worse in the back: nux v. 

Pains worse in the abdomen : pulsatilla. 

Pains run upward: lycopodium. 

Pains like needles in the cervix, especially with rigid os : cau- 
lophyllum. 

Special and peculiar Symptoms. — Cardiac neuralgia in 
parturition: actaea. 

During labor cannot bear to have her hands touched : china. 

With every uterine contraction, violent dispnocea which seems 
to neutralize the labor-pams: lobelia. 

Labor progresses slowly, pains feeble, seemingly from sad 
feelings, and forebodings : not. mur. 

Cessation of labor-pains; retention of stool and urine, often 
from fright: opium. 

Contractions interrupted by sensitiveness of vagina and vulva : 
platina. 



CHAPTEK IY. 

Use of Anaesthetics in Midwifery Practice. 

■ In treating the subject of anesthetics in obstetrical practice, 
we should divide cases into two general classes: 1. Cases of 
normal labor, wherein we seek merely to mitigate the ordinary 
pangs of childbirth, and 2. Cases of an abnormal, or unusual, 
nature, wherein operative interference is adopted. 



ANESTHETICS IN NORMAL LABOR. 327 

1. Cases of Normal Labor. — The use of anaesthetics in 
normal labor, differs essentially from its employment elsewhere, 
in the design of its employment, and the extent to which its ac- 
tion is carried. We aim in snch cases not to completely annul 
sensibility, and subdue muscular resistance; but merely to mod- 
ify the agony associated with the propulsive stage of labor. 
When from purpose or accident the anaesthetic influence is per- 
mitted to exceed this limit, new dangers arise, and fresh compli- 
cations are met. To accomplish our purpose, continuous inha- 
lation is not required, and should not be permitted, but the 
lethean vapors ought to be applied just before and during the 
pains. 

The form of anaesthetic best adapted to such purposes is un- 
questionably chloroform. It is more speedy, pleasant, and 
energetic in its effects than ether, and in parturition it has proved 
to be quite as safe. In surgical practice its effects have occa- 
sionally proved fatal, but when administered during labor, ac- 
cording to the directions which follow, scarcely a death has 
resulted. 

Parturient women are easily put under its influence to the 
extent required for present purposes ; a few inhalations of its 
vapors, begun just before the expected recurrence of a pain, and 
continued during it, being sufficient to allay excessive sensibility, 
and quiet the nervous erethism so often observed. The nurse, 
or some self-possessed assistant, is instructed to pour upon a 
folded handkerchief or napkin fifteen or twenty drops of the 
chloroform, and place it within about half an inch of the nose 
and mouth, thereby giving free access to atmospheric air. None 
of the chloroform should be permitted to touch the patient's 
skin, as the smarting produced by it would be liable to excite 
fear. It is a good plan to apply the chloroform to the handker- 
chief soon after the close of a pain, and then roll the latter 
tightly in the hand to prevent evaporation, until the pain is 
about to return. Otherwise there is liability to delay, and the 
patient is as greatly annoyed by the bungling work of the per- 
son in charge of the anaesthetic, as by the labor-pains themselves. 
By such administration of chloroform, consciousness is not im- 
paired, and the patient may at the time declare that her suffer- 
ings are nearly as keen as before ; but when the labor is past, she 
is enthusiastic in her praise of the virtues of the anaesthetic. 



328 THE USE OF ANESTHETICS. 

Women who have once taken it, are not willing to be deprived 
of its soothing influences in subsequent labors. 

The usual objections raised against the use of chloroform in 
labor, are not here forcible, since the effect is so moderate that 
it is not capable of materially modifying the pains, precipitating 
post-partum hemorrhage, or producing any of the other ills 
sometimes attributable to a use of the drug under different cir- 
cumstances. 

The period in labor when the use of an anaesthetic should be 
adopted, varies in different cases. It is wise, however, to defer it 
until near the close of the second stage. When once begun, its 
action must be maintained until the close of foetal expulsion, as 
the woman will not tolerate a suspension of the pain-soothing 
influences. Hence, to begin early, involves a long continuance. 
The most intense pain is suffered in the latter portion of the 
propulsive stage, and this part of labor, if any, ought to be 
lightened. In some instances of extreme excitability, and terri- 
ble suffering, the chloroform may, with perfect propriety, be 
earlier exhibited. 

2. The Use of Anaesthetics in Operative Midwifery.— 

The effect of the anaesthetic, in those cases where operative pro- 
cedures are necessary, is carried to a greater extent, and, possi- 
bly, involves the patient in greater danger. That there is a cer- 
tain degree of peril to life associated with the administration of 
any anaesthetic, no one will question, and that it is greater in 
the instance of chloroform, none who have familiarized them- 
selves with the general subject of anaesthetics will presume to 
deny. Every few weeks a case of death under chloroform finds 
its way into public print, thus giving strength to popular fear. 
And yet a careful analysis of such fatalities generally discloses, 
as an efficient cause of the accident, a flagrant disregard of the 
rules laid down for the administration of this potent, and hence 
dangerous, substance. The fatalities occurring in the dentist's 
chair largely preponderate, the patient occupying a semi-recum- 
bent position, which is wholly at variance with that prescribed 
upon physiological principles. 

Attention should be directed to the difference in point of mor- 
tality under anaesthetics between surgical and obstetrical 
patients. In surgery we have many recorded cases of death, 
and their number is being augmented from time to time ; but 



ANAESTHETICS IN OPEBATIYE MIDWIFEEY. 329 

this is not true of midwifery. In fact, but few fatal cases in the 
latter branch of practice have ever gone upon record. The ex- 
planation of such divergent results is not altogether satisfactory, 
but it may be found in the increased cardiac energy growing out 
of the circulatory changes of pregnancy, elsewhere described. 
But whatever our theories regarding the cause, the truth re- 
mains, and has become familiar, even to the general public. 

Anaesthetics are said to predispose to post-partum hemor- 
rhage, which is generally a complication directly dependent on 
atony of the uterine muscles. Extreme vascular fullness is 
maintained by the flaccidity of the tissues, while the exposed 
vessels at the placental site freely bleed. The effect of anaes- 
thetics on uterine contraction is marked, as the author has re- 
peatedly demonstrated. This effect is rather more decided in 
chloroform than in ether inhalation. A moderate degree of 
anaesthesia may be produced without essentially modifying uter- 
ine action; but as the impression becomes more profound, the 
contracting organ is partially or wholly subdued. If this is the 
effect of anaesthetics on the uterus during labor, when the organ 
is stimulated to action by its contents, we should be prepared to 
find a corresponding condition protracted somewhat into the 
post-partum stage. That we do find more or less relaxation af- 
ter extrusion of the foetus and secundines in such cases, is be- 
yond question; and yet it is not so marked, nor so persistent, as 
some suppose. Remove the vapors from the woman's nostrils 
during labor, and the contractions which have been extremely 
feeble, or altogether absent, are soon renewed. In like manner 
after delivery, when the more profound effects of the chloroform 
pass away, uterine atony generally gives place to a favorable 
tone of the muscular fibre. The result is that hemorrhage of 
moment rarely ensues. Occasionally there is a sudden profuse 
gush of blood soon after the placenta is removed, especially 
when the anaesthetic influence has been maintained to the very 
close of the second stage, or longer; but hypogastric pressure, 
and moderate use of cold water, are nearly always capable of 
speedily arresting the flow. In the Hahnemann Hospital it is 
our custom, as a preliminary to the introduction of a class of 
students, to bring the woman profoundly under the influence of 
chloroform; and though narcosis is frequently maintained for a 
period of one and a half, or two hours, among the hundreds of 



330 



THE USE OF ANAESTHETICS. 



women confined there during the past few years, not a single 
case of alarming hemorrhage has been met. Our practice is to 
keep a close watch over the patient for a considerable time af- 
ter delivery, and give attention to the first indication of trouble. 
Pressure is made on, the fundus uteri for fifteen or twenty min- 
utes after foetal and placental expulsion, in ordinary cases, and 
longer in those presenting suspicious symptoms. If the uterus 
is felt to relax beyond a normal limit, and does not respond at 
once to abdominal pressure, the vulva is inspected, and, if nec- 
essary, cold applications, and manual irritation of the os uteri, 
are employed. It is rare that more energetic measures are 
required. 

The question has often been asked — Does an anaesthetic ad- 
ministered to the mother, produce any effect on the child in 
utero? We have been led by experience to give an affirmative 
reply. For example, in a difficult instrumental case which came 
under the writer's care, wherein sulphuric ether was adminis- 
tered for an uncommonly long time, the child, though but a few 
minutes before birth it was proved by auscultation to be living,, 
was still-born, and resisted all efforts at resuscitation. About 
forty-eight hours subsequently, dissection of it was begun by 
some students, and when the viscera were exposed, the odor of 
ether was distinctly observed. 

In most instances, where the mother has been long subjected 
to anaesthesia, the child is comparatively inactive for some time 
after expulsion. It is really uncommon for children born under 
such conditions to utter the cries so generally heard at the birth 
of children whose mothers have not been under anaesthetic in- 
fluences. And yet, that decidedly deleterious effects are often 
produced, there is much reason to doubt. 






Rules for Administering Anaesthetics. — The general rules 
for administering anaesthetics are pretty well understood, even 
by tyros, and still there is frequent disregard of them. The 
mode of administering chloroform differs materially from that 
of ether. In bringing a patient under the influence of the lat- 
ter, a cone, or an inhaler of some other form, is generally em- 
ployed, which is held closely down over the nose and mouth, so 
that all the atmosphere which enters the lungs is loaded with 
ether vapors, taken from the saturated sponge in the apex of the 



RULES FOE ADMINISTERING. 



331 




Fig. 128 



cone. Such a use of chloroform would be dangerous in the ex- 
treme. In its administration the following rules should be ob- 
served: 

Fig. 127. First: — The patient must occupy the 

recumbent posture. 

Second: — The article or apparatus by- 
means of which the chloroform vapors 
are conveyed to the patient, must be so 
placed or arranged, as not to exclude a 
moderately free supply of atmospheric 
air. 

Third: — Both respiration and pulse 
should be attentively observed from first 
to last. 

Deviation from a horizontal position 
Allis 1 Ether Inhaler. augments the patient's danger, as has 
been repeatedly demonstrated in fatal cases. 

The supply of atmospheric air must be more copious than is 
afforded with ether inhalation. A fold- 
ed handkerchief, or napkin, is a conven- 
ient medium, on which should be poured 
but a small quantity at a time, and then 
placed within one-half or three-quarters 
of an inch of the patient's mouth and 
nose. ' The patient should be directed to 
breathe deeply and regularly, while fear 
and excitement ought to be allayed as 
far as possible, by cheerful words and a 
calm bearing. The supply of chlor- 
oform may be renewed as often as cir- 
cumstances seem to require, the inter- 
vals being varied to correspond with the 
woman's condition, and the facility with 
which anaesthesia is produced. These 
are important considerations, since it is 
very certain that danger bears a marked 
relation to the intensity of the impress- 
ion, and the rapidity of its production. 

* This inhaler takes up little room in the obstetrical hag, or even the pocket, 
and is a very convenient article to carry. 




Chisolm's Ether Inhaler. 






332 THE MECHANISM OF LABOP 

Neither anaesthetic should be administered without the closest 
attention being directed to the pulse and respiration. When 
employed in normal labor for the purpose merely of dulling the 
sensibilities, this is hardly so essential, though it should not be 
forgotten that in other than midwifery cases, death has occurred, 
in quite a proportion of instances, at the very beginning of the an- 
aesthetic process. When carried to the extent of complete nar- 
cosis, the rule must be scrupulously adhered to, if one would 
keep within the bounds of comparative safety. Nor should these 
observations be intrusted to a person wholly unacquainted with 
the phenomena developed by anaesthetics, if it is possible to 
secure the aid of one qualified to fill the position. To do other- 
wise is to subject the woman's life to unnecessary risk, one's 
self to much solicitude, and to merited denunciation in case of a 
fatal result. 

After making the most elaborate provision for the administra- 
tion of this powerful drug, the operator should on no account 
suffer himself to become oblivious to his patient's condition. 
When the operation is difficult, and attended with vexatious 
occurrences, one easily becomes so deeply engaged in the work 
immediately in hand as to remit his watchfulness over impor- 
tant concomitants — a state of mind against which he cannot be 
too guarded. 

We shall not here enter into an account of the symptoms of 
fatal cases, or the treatment to be adopted; but for an extended 
discussion of these we refer the student to elaborate works on 
surgery, and to special treatises. 



CHAPTEE V. 

The Mechanism of Labor. 

The Various Positions of the Foetus. — This is a subject 
which, to the student, is full of difficulty, and to elucidate it is 
no easy task. One of the most conspicuous factors in the pro- 
duction of confusion is the adoption of numerals to designate 
the various positions which are met. Every presentation has 
four positions, which are designated by the numbers one, two, 



POSITIONS OF THE FCETUS. 333 

three and four. For example, the left occipito-anterior position 
is the first, and the right occipito-anterior is the second. The 
adoption of these designations, it must be confessed, is a saving 
of some words at the moment; but to give the student a per- 
spicuous and comprehensive view of the different positions, and 
their relations, demands an exhaustive, and, we may add, unnec- 
essary effort. 

As a preliminary to the study of this subject one must have a 
clear conception of the cardinal features of the pelvis, which 
have been elsewhere pointed out. With a knowledge of the 
form of the pelvic brim, outlet and cavity, the situation of the 
ileo-pectineal eminence and the acetabulum, and the relative 
measurements of the various diameters, and finally the bounda- 
ries of the false and the true pelvis, one is prepared to under- 
stand that which here follows. 

The Theory of Classification.— The four positions into 
which the various presentations are divided, are based upon the 
theory that the long diameter of the presenting part occupies an 
oblique position with reference to the pelvis. That the theory 
does not hold true in all cases, is manifest to every obstetric 
practitioner. The long diameter is sometimes, though rarely, at 
the brim, in the conjugate of the pelvis; and again it occupies 
the transverse diameter. In the latter instance it always rotates 
into an oblique diameter, soon or late, and tnerefore becomes 
one of the regular positions; while instances of the former are 
so rare as to make a single exception of no great importance. 
For practical, as well as theoretical purposes, perspicuity would 
lead to an approval of the division. 

When the vertex presents, the occiput is regarded as the car- 
dinal feature, since it is in advance, and from the direction it 
assumes, the positions are described, or numbered. With the 
long diameter of the head in an oblique pelvic diameter, the oc- 
ciput must be either forward and to the left, or backward and 
to the right; forward and to the right, or backward and to the left. 
When forward and to the left it is the first position; when for- 
ward and to the right it is the second position; when backward 
and to the right it is the third position; and when backward 
and to the left it is the fourth. 

When the face presents, the chin corresponds, so far as the 
mechanism of labor is concerned, to the occiput in vertex pres- 



334 



THE MECHANISM OF LABOR. 



entation, and the direction of that part determines the position. 

When backward and to the right it is the first position; when 

Fig. 129. Fig. 130. 




First Position of the Vertex. 
Fig. 131. 



Second Position of the Vertex. 
Fig. 132. 




Third Position of the Vertex. Fourth Position of theVertex. 

backward and to the left, the second; when forward and to the 
left, the third; and when forward and to the right, the fourth. 



THEOEY OF CLASSIFICATION. 



335 



When the pelvic extremity presents, one pole of the long 
diameter does not take precedence over the other, since it is 
Fig. 133. Fig. 134. 




First Position of the Breech. 
Fig. 135. 



Second Position of the Breech. 
Fig. 136. 




Third Position of the Breech. Fourth Position of the Breech, 

immaterial to the easy and natural performance of the mechan- 
ism of labor whether the right or the left trochanter is turned 



336 



THE MECHANISM OF LABOR. 



forward. When the bi-trochanteric diameter is in the left ob- 
lique pelvic diameter, and the left hip is forward and to the 
FlG> 137. right, it is the first position; 

when in the right oblique dia- 
meter, and the right hip is 
forward and to the left, it is 
the second position; when -in 
the left oblique and the right 
hip is forward and to the 
right, it is the third position; 
and when in the right oblique 
diameter, with the left hip 
forward and to the left, it is 
the fourth position. 

When the foetus presents 
transversely, four positions 
may also be described. If 
the dorsum is forward, and 
the head lies to the right, it 
is the first position; if the dorsum is forward, and the head lies 
to the left, it is the second position ; when the dorsum is back- 

Fig. 138. 




Fourth Position of the Feet. 




Third Position of Transverse Presentation, 
ward, and the head lies to the left, it is the third; and when 



THE BASIS OF CLASSIFICATION. 



337 



the dorsum is backward, and the head lies to the right, it is 
the fourth. 

Fig. 139. 




Second Position of Transverse Presentation. 

These are the four positions of the various presentations. 
They have been otherwise named by some authors. 

The Basis of Classification. — It must not be supposed that 
the classification of positions is made upon mere arbitrary prin- 
ciples, though from the first study of it this may seem to be 
true. Our attention has thus far been addressed to the various 
features of the presenting parts, but we will now regard the po- 
sition of the trunk. 

With respect to the direction of the back, it should be said 
that, like the position of the head, it is not always oblique; still 
practical, as well as theoretical, purposes are just as well served 
— we may say, are better served — by assuming that it is. The 
long axis (bis-achromial) of the trunk forms a right angle with 
the long axis (occipito-frontal in vertex presentation, and 
f ronto-mental in face, ) of the head. Accordingly we observe 
that the dorsum of the foetus coincides with the occipital pole 
of the long diameter of the vertex, and the frontal pole of the 
long diameter of the face. The bi-trochanteric diameter of the 
pelvis is the long diameter of the presenting part, when the pel- 
vic end is in advance. In the first position of vertex presenta- 
tion the occiput lies to the left ilio-pectineal eminence, and con- 



338 



THE MECHANISM OF LABOE. 



stitutes the left occipito-anterior position. Now, assuming, as 
we do, that the f oetal back corresponds in direction to the occi- 
put, this position might well be designated as the left dorso- 
anterior position of the vertex. Let us now reverse the ends 
and cause the breech to present in the first position, and we 
have the left dorso-anterior position of this presentation. We 
will now return the child to the first position of the vertex, and 
then, by extension of the head, i. e., by tipping the head back- 
Fig. 140. Fig. 141. 




First Position of the Vertex. 



First Position of the Breech. 



wards, we convert it into the first position of the face, and we 
find that this may likewise be described as the left dorso-ante- 
rior position — not of the vertex, not of the breech — but of the 
face. Furthermore, we will now turn the head away from the 
brim and lay it in the right iliac fossa, and we have the first 
position of transverse presentation, which may also be desig- 
nated as left dorso-anterior. 

What is true of the first position is also true of the second, 
third, and fourth positions. In the second position the dorsum 
of the foetus is forward and to the right, and it may be graphi- 
cally described as right dorso-anterior. When the head pre- 
sents, it is right dorso-anterior position of the vertex or face; 
when the pelvis presents, it is right dorso-anterior of the breech, 
knees or feet; and when the presentation is of the side of the 



THE BASIS OF CLASSIFICATION. 



339 



foetal oval, then briefly, it may still be designated as right dorso- 
anterior position. In the third position of any presentation, the 
back of the fcetns lies backward and toward the woman's right; 
and in the fourth position of any presentation, the dorsum is 
turned backwards and toward the woman's left. By such gen- 
eralization, we obtain a comprehensive view of the entire sub- 
ject of positions. 

Fig. 142. Fig. 143. 




Second Position of the Vertex. 



Second Position of the Breech. 



From what has been given on this topic we may draw the fol- 
lowing conclusions: 

First: That the underlying principle of classification is not 
so much the direction of the cardinal features of the presenting 
part, as the direction of the foetal dorsum. 

Second: That the first and second positions of all presenta- 
tions, are dorso-anterior, — the first, left dorso-anterior, the sec- 
ond, right dorso-anterior; and the third and fourth positions are 
always dorso-posterior, — the third being right dorso-posterior, 
and the fourth, left dorso-posterior. 

Third: That in the first and fourth positions of all presenta- 
tions, the dorsum of the foetus is directed toward the woman's 
left, — the first somewhat forwards, the fourth somewhat back- 
wards; and in the second and third positions of all presentations, 



340 THE MECHANISM OF LABOE. 

the dorsum is turned toward the mother's right, — the second, 
somewhat forwards, the third, somewhat backwards. 

The Relative Frequency of Positions. — Of vertex presen- 
tations the back of the child is directed to the left of the mother 
in about seventy per cent, of all cases. With regard to the fre- 
quency of other positions there is much discordance of opinion, 
but the author's experience leads him to the conclusion that the 
frequency of the several positions is in the order in which they 
are numbered. 

While the relative frequency of the various positions cannot 
yet be determined for want of recorded observations, it appears 
that while in vertex presentations the dorsal surface of the foetus 
is turned toward the mother's left in about seventy per cent, of 
all cases, in face presentations this position does not preponder- 
ate. 

Points of Coincidence Between the Yarious Positions.— 

In vertex presentation the first and second positions agree in one 
particular, namely: they are both occipito-anterior positions; — 
the first looking to the left, the second to the right; and the third 
and fourth agree in being occipito-posterior positions, — the third 
directed toward the right, and the fourth toward the left. The 
first and fourth correspond in being left occipital positions ; that 
is to say, the occiput in both instances is turned toward the left, 
— in the first, somewhat forward, in the fourth, somewhat back- 
ward. The second and third are alike in the general direction 
of the occiput, — both looking to the right, — the second turned 
somewhat forward, and the third somewhat backward. Again, 
the first and third agree in respect to the oblique pelvic diame- 
ter (right oblique) in which they lie, but the poles are reversed, 
so that the first is the left occipito-anterior position, and the 
third the right occipito-posterior. The second and fourth cor- 
respond in similar respects. They occupy the left oblique pel- 
vic diameter, the second being the right occipito-anterior, and 
the fourth the left occipito-posterior position. 

Face Presentation.— Briefly stated, the positions of the face 
coincide in certain particulars which are determined by similar 
principles of classification as are those of the vertex. The fiist 
and second are mento-posterior positions, the chin in the first 
looking to the right, and in the second, to the left. The third 



POINTS OF COINCIDENCE, ETC. 341 

and fourth are mento-anterior positions, the chin in the third 
being directed to the left, and in the fourth, to the right. The 
first and fourth correspond in the lateral direction of the chin, 
in the first it being backwards and to the right, and in the 
fourth, forward and to the right. The coincidence between the 
second and third is similar, in the second the direction being 
backward to the left, and in the third forward to the left. 

The first and third, and the second and fourth are alike in the 
pelvic diameters occupied by the long facial diameter, the first 
being right mento-posterior, and the third, left mento-anterior; 
while the second is left mento-posterior, and the fourth right 
mento-anterior. 

Breech Presentation. — The first and second positions of the 
breech agree in that the right trochanter of the foetus looks 
toward the left in the first position, somewhat backward, and in 
the second forward. Likewise the third and fourth positions 
resemble one another in that the right trochanter is turned to 
the mother's right, in the third position it being forward, and in 
the fourth backward. The first and third are identical in the 
direction of the bi-trochanteric diameter (left oblique), but in 
the first position the right trochanter is at the left ilio-sacral 
synchondrosis, and in the third is at the right ilio-pectineal em- 
inence. The second and fourth positions coincide in the pelvic 
diameter occupied (right oblique), but in the second the right 
trochanter is at the left ilio-pectineal eminence, and in the fourth, 
at the right ilio-sacral synchondrosis. 



CHAPTEE VI. 

The Mechanism of Labor,— (Continued.) 

The mechanism of labor, varies greatly with the character of 
the presentation. The varieties of these, and their positions, 
have already received attention, and but a few general remarks 
need be made here with regard to them. Vertex presentation 
represents the normal type of labor, and is alone entitled to be 
regarded as strictly normal. The other varieties are relatively 



342 THE MECHANISM OF LABOR. 

infrequent, and present characters which deviate from the phe- 
nomena usually observed. 

Yertex Presentations. — Some of the ancients believed that 
the head passed through the pelvis in the same manner as a 
semi-organized clot of blood, or a mass of hardened feces, with- 
out reference to those nice laws of flexion, rotation, extension 
and restitution, now so well understood to have an important 
bearing in every case. Others believed that the child by its 
own spontaneous efforts pushed its way through the pelvis — that 
it verily crept into the world. The origin of the present theo- 
ries regarding the mechanism of labor may be traced to Sir 
Fielding Ould, who in 1742 published a work which contained 
some of the ideas still extant. In 1771, Saxtorph, of Copenhagen, 
and Solayres de Renhac, of Montpellier, simultaneously, and 
without mutual consultation or knowledge, published essays 
which agreed that in natural labor the long diameter of the 
child's head enters the pelvis in an oblique direction, and that in 
a large proportion of instances it occupies the right-oblique di- 
ameter, the poles of which are the left ilio-pectineal eminence, 
and the right ilio-sacral synchondrosis. Through the strong 
advocacy of Baudelocque these ideas were quite generally ac- 
cepted, but certain erroneous notions crept in, and the matter 
was finally cleared up and simplified by Naegele, of Heidelberg, 
in 1818. 

Vertex. — The term "vertex" will be understood to signify 
the upper surface of the head, but it may be well to say that by 
it is meant the crown, or that part of the head embraced within 
the limits of lines connecting the posterior fontanelle, the parie- 
tal eminences, and the anterior fontanelle. 

Relative Frequency of Yertex Presentations.— Out of 93,- 
871 births collected by Spiegelberg, from private practice, in 
over ninety-seven per cent, the vertex presented.* The proba- 
ble cause of this has already been considered. 

Relative Frequency of First Position.— As elsewhere stated, 
the first position of the vertex is found in a very large proportion 
of cases. The cause of this is not understood, but Simpson at- 

* " Lehrbuch der Geburtslmlfe," p. 148. 



MECHANISM OF OCCIPITO-ANTEMOR POSITIONS. 



343 



tributes it to the presence of the rectum on the left side of the 
pelvic brim. 

It has been suggested that it probably results from the fact 
that the uterus is usually rotated in such a way upon the spine, 
that the right side inclines obliquely backward, while the left 
side is turned somewhat toward the front. 

Conditions at the Beginning of Labor. — At the beginning 
of labor, the presenting head, covered by the uterine tissues, is 
found at the brim, or below it, and occupies with its long diam- 
eter, an oblique diameter of the pelvis. 

Conditions of the Foetns Which Favor Expulsion. — The 
mechanism of labor in head presentations is usually described as 
consisting of a series of movements, termed, 1. descent, 2. flex- 
ion, 3. rotation, 4. extension, 5. restitution. 

A knowledge of these, as they occur in labor, is highly essen- 
tial to a proper comprehension of the mechanism of parturition, 
and the intelligent practice of the obstetric art. 

Mechanism of Labor in the First, or Left Occipito- Anterior 
Position. — It should be remembered that, in the first position of 
the vertex, the long diameter of the head occupies the right 
Fig. 144. oblique diameter of the pelvis, 

the occiput being directed to 
the left ilio-pectineal emi- 
nence, and the forehead to 
the right sacro-iliac synchon- 
drosis. The dorsum of the 
foetus is thus brought to the 
mother's left side. 

Parallelism of the Bi- 
parietal Plane to the Plane 
of the Brim.— The head .baa 
usually been described as en- 
tering the brim with the right 
parietal eminence on a lower 
plane than the left; but this 
idea is being abandoned. The 
First Position of the Vertex. plane of the brim and the bi- 

parietal plane are probably 
at that moment coincident. 




344 THE MECHANISM OF LABOE. 

Descent and Flexion. — Descent and flexion are closely allied 
movements. As the head descends and encounters the bounda- 
ries of the brim, the force is such as to cause flexion. The long 
diameter of the head represents a lever, with the fulcrum at the 
occipito-atantloid articulation, the anterior being the long arm and 
the posterior the short. It is clear then, that, as the head de- 
scends and meets resistance at the brim, the force transmitted 
through the spine will cause the descent of the occiput, and effect 
flexion of the chin on the sternum. The degree of flexion will 
be proportioned to the extent of the action, and the force and 
extent of resistance encountered. 

Direct Descent of the Head. — The descent of the head does 
not, in the early part of its course, closely follow the axis of the 
pelvic canal; but the movement is directly downwards and back- 
wards in the axis of the brim, until it approaches the floor of the 
pelvis, and meets there with resistance which turns it forward to 
the pubic arch. 

Passage through the Pelvic Cavity.— As the head passes 
through the cervix uteri, flexion usually becomes extensive, so 
that the chin is pressed well upon the sternum. This in some 
cases not being requisite, does not occur, the head being unusu- 
ally small, or the cervix exceptionally soft and dilatable. The 
advantage of this condition of flexion is plain, since it will be 
seen that by means of it, shorter diameters are brought to bear 
upon the pelvic dimensions. 

A further advantage derived from head flexion has been de- 
scribed by Pajot :* " The foetus in its entirety may be regarded 
as a broken, vacillating rod, which is moveable at the articula- 
tion of the head and trunk, but a solid thus disposed presents 
conditions unfavorable to the transmission of a force acting prin- 
cipally upon one of its extremities; it follows, therefore, that, 
previous to flexion, the uterine action, pressing upon the pelvic 
extremity to promote the advance of the foetus, is lost in great 
measure in its passage from the trunk to the head, by reason of 
the mobility of the latter; but the cephalic extremity, once fixed 
upon the thorax, is most advantageously disposed to participate 
in the impulse communicated to the general mass of the fcetus. 

* Quoted by TAENIEE et CHANTEEUIL, p. 639. 



MECHANISM OF OCCTPITO-ANTEKIOE POSITIONS. 



345 



The head, having accomplished the movement of direct de- 
scent, and having cleared itself from the trammels of the cervix 
uteri, becomes again somewhat extended. But, as it thus presses 
on the smooth pelvic floor, the occiput very naturally glides in 
Fig. 145. the direction of least resist- 

ance, flexion is again firm, 
and rotation of the head oc- 
curs, by means of which its 
long diameter moves from the 
right oblique to the conjugate 
diameter of the pelvis, and 
the occiput slips under the 
pubic arch. The spines of 
the ischia have been said to 
act an important part in rota- 
tion, but we are inclined to 
deny them the title of " key 
to the mechanism of labor." 
Since it is always the most de- 
pendent part which rotates to 
the front, a moment's reflec- 
tion will enable us to see that 
rotation, therefore, takes place in such a direction that the 
sloping surface of the foetal head corresponds with the incline 
of the perineum. The law which controls the movement of 
the foetal head known as rotation, is based upon the mechan- 
ical principle that, when a body is subjected to pressure, its move- 
ment will always be in the direction of least resistance. Rotation 
is not always complete, the long diameter of the head still pre- 
serving some of its original obliquity. 

At the outlet there may be a certain amount of biparietal 
obliquity, and accordingly the right parietal eminence is born in 
advance of the left. These obliquities, however, are of compar- 
atively little importance, and should not be regarded as essentials 
in the mechanism of labor, as are the movements of flexion and 
rotation. 




Showing the lateral obliquity of the 
head with reference to the horizon in 
the pelvic cavity in the first position. 



Passage of the Head Through the Outlet.— Flexion at this 
part of labor should be firm, so as to bring the shorter diameters 
of the head into the strait. At the same time the occiput glides 



346 



THE MECHANISM OF LABOR. 



under the pubic arch, and becomes the centre of another move- 
ment which is now begun, viz., extension. The occiput being 
fixed under the arch, is prevented, by the nape of the foetal neck, 

from further advance, and the di- 
Fig. 146. rection of least resistence is chang- 

ed, so that now the perineum is 
distended, and by the movement 
of extension alluded to, the head 
passes the vulva. 

Restitution, or External Ro- 
tation. — After birth of the head, a 
movement of accommodation, 
known as restitution, or external 
rotation, takes place, which is noth- 
ing more than the face turning in 
this case to the mother's right 
thigh. This change is effected 
mainly by the shoulders which are 
yet to be delivered, the long, or 
bis-acromial diameter of which now 
seeks the pelvic conjugate. This 
is an important movement. The 
long diameter of the vertex, and 
the long diameter of the shoulders, 
naturally assume directions at right 
angles to one another. In the first 
position, the vertex lies with its 
long axis in the right oblique dia- 
meter of the pelvis, and the bis- 
acromial axis in a converse direction. During rotation of the 
head in the pelvic cavity, the position of the shoulders does not 
materially change, and after the head escapes, it forsakes its 
constrained position, and is restored to its original, or, at least, 
its recent direction, — hence the name of the movement, — resti- 
tution. But this does not complete the movement, for, no soon- 
er has the head fairly escaped than the shoulders begin to ad- 
just themselves to the outlet, by turning their long diameter in- 
to the conjugate, and as this change occurs, the head is still 




0. B. short arm of head lever 
B F. long arm of head lever. 



MECHAN^M OF OCCIPITO-ANTERIOR POSITIONS. 



347 



further rotated, until the face looks pretty squarely to the moth- 
er's right thigh. 
While this is the usual phenomena, others are sometimes 

Fig. 147. 

I 




The head approaching the outlet in the first position. 
Fig. 148. 




The mechanism of lahor in the first position. 
observed to substitute them. It would occasionally appear that 
rotation of the shoulders does take place simultaneously with 



348 



THE MECHANISM OF LABOE. 



that of the head, in which case the bis-acromial diameter comes 
to lie at the brim, or in the cavity, in a transverse direction, and 
when the shoulder rotation, preparatory to escape from the out- 
let, comes to be made, the unusual direction is taken, and as a 
result, the face is observed to turn toward the mother's left thigh. 
The author has seen several marked instances of this kind. 

The term restitution has by some been limited to the first part 
of the movement described, while the balance is called external 
rotation. 



Expulsion of the Trunk. — After birth of the head there is 
generally a longer or shorter rest, and upon the renewal of pain, 
the right shoulder is directed forward by the right anterior 
ischial plane, while the left glides backward over the left poste- 
rior plane, into the sacral hollow. This movement is often quite 
sudden, and is accomplished only as the part actually passes the 
vulva, which it must do with a spiral motion. The body is bent 
upon itself, and the left shoulder is driven downward until it 
shows at the posterior commissure, when the right slips under 
the pubic arch, and finally both emerge almost simultaneously. 
Fig. 149. If the arms are flexed, the el- 

bows pass with a jerk, and some- 
times produce laceration of the 
perineum. The trunk easily fol- 
lows the shoulders, and the en- 
tire body is speedily born. 

Mechanism of the Second, 
or Right Occipitoanterior 
Position.— In the second posi- 
tion of the vertex the long dia- 
meter lies in the left oblique dia- 
meter of the pelvis, and the occi- 
put looks forward and to the 
right ilio-pectineal eminence, or 
acetabulum, and the forehead to- 
ward the left ilio-sacral syn- 
chondrosis. The same general 
movements are performed, 
viz., descent, flexion, rotation, extension, and restitution; but 
the directions are changed. Eotation in the pelvic cavity is 




Second Position of the Vertex. 



MECHANISM OF OCCTPITO-POSTERIOR POSITIONS. 



349 



from right to left, instead of left to right, and external rotation 
takes place by the face turning toward the mother's left thigh, 
instead of her right. The left shoulder rotates from the left 
side to the pubic arch, whereas, in, the first position, the right 
shoulder rotates from the right side forwards. Further material 
differences than these do not exist, and we accordingly omit a 
detailed description of the mechanism of this position. 

Fig. 150. Fig. 151. 




Third Position of the Vertex. Fourth Position of the Vertex. 

Mechanism of the Occipito-Posterior Positions.— The oc- 

cipito-posterior positions are the third and fourth, in the former 
of which the occiput lies toward the right ilio-sacral synchon- 
drosis, and in the latter to the left ilio-sacral synchondrosis. 
The third position occupies the same oblique diameter as the 
first, and the fourth the same diameter as the second, but the 
poles are reversed. "What creates the particular interest in con- 
nection with these positions is the extensive rotation by which 
the occiput is brought to the pubic arch. In occipito-anterior 
positions, the rotation is but slight, and easily accomplished; 
while in occipito-posterior positions it is extensive, and, from 
the contingencies attending it, is not always properly performed. 
Kotation of the occiput forward is accomplished by the short- 
est route; the third position, during the performance of this act, 
becoming the second, and the fourth, the first. 



350 THE MECHANISM OF LABOR. 

In exceptional, but by no means rare, cases, the occiput, 
owing to the existence of unfavorable mechanical conditions, is 
thrown backwards into the sacral hollow. An occipito-poste- 
rior termination of labor is more difficult and dangerous than 

Fig. 152. 




Third position of the vertex, as seen from above. 

an anterior, because the head has to be subjected to greater 
moulding, and even then longer diameters are brought to bear. 
The occiput in such a case, after much effort, slips through the 
vulva, and rests upon the perineum, upon which, as a pivot, the 
head rotates in the movement of extension, until it ultimately 
passes. The movements described as taking place in the first 
position, occur here also. Flexion is, or should be, firm ; rota- 
tion should take place as described; extension is observed at the 
vulva, and restitution occurs after head expulsion. When ro- 
tation is properly accomplished, the third becomes, as stated, the 
second, and the fourth the first; from which point onward their 
movements are identical. When labor terminates in an occi- 
pito-posterior position, the face of the child turns, in restitu- 
tion, in the third position to the mother's left thigh, and in the 
fourth, to the right thigh. 

With regard to the causes which determine rotation forward 
of the occiput, the following experiments of Dubois will be in- 
structive : "Ina woman who had died a short time before in 
child-bed, the uterus, which had remained flaccid, and of large 
size, was opened to the cervical orifice, and held by aids in a 
suitable position above the superior strait; the foetus of the 
woman was then placed in the soft and dilated uterine orifice in 
the right occipito-posterior position. Several pupil-midwives, 
pushing the foetus from above, readily caused it to enter the 



MECHANISM OF OCCIPITO-POSTERIOR POSITIONS. 



351 



cavity of the pelvis; much greater effort was needed to make the 
head travel over the perineum and clear the vulva; but it was 
not without astonishment that we saw, in three successive at- 
tempts, that when the head had traversed the external genital 
organs, the occiput had turned to the right anterior position, 

Fig. 153. 




Occipito-posterior termination of the third position of the vertex. 

while the face had turned to the left and to the rear; in a word, 
rotation had taken place as in natural labor. We repeated the 
experiment a fourth time, but as the head cleared the vulva the 
occiput remained posterior. Then we took a dead-born foetus 
of the previous night, but of much larger size than the preced- 
ing; we placed it in the same conditions as the first, and twice 
in succession witnessed the head clear the vulva after having 
executed the movement of rotation. Upon the third and follow- 
ing essays, delivery was accomplished without the occurrence of 
rotation; thus the movement only ceased after the perineum and 



352 THE MECHANISM OF LABOB. 

vulva had lost the resistance which had made it necessary, or, 
at least, had been the provoking cause of its accomplishment."* 

High Rotation. — "Rotation," says Leishman,f very truly, 
" at an early stage of labor, before it is yet practicable to ascer- 
tain the actual position of the head with anything like cer^ 
tainty, is probably of much more frequent occurrence than we 
have any idea of. Few things are more familiar to the experi- 
enced accoucheur than a rotary or rolling movement of the head, 
which he observes either during a pain or an interval, while it 
is still high in the pelvis. This is due partly to uterine action, 
and partly to the movements of the foetus, and we have no doubt 
that, by this means, many unnatural and faulty positions are 
rectified even after labor has commenced; and we are further 
entitled to assume that in this way many occipito-posterior po- 
sitions are rectified at such a stage that their detection is ren- 
dered impossible. It should always be remembered that the 
dorso, or occipito-anterior position of the child is the natural 
one, and that according to which the irregular oval which it 
forms is most conveniently disposed." 

Conversion of Occipito-Posterior Into Occipito- Anterior 
Positions. — A very important question of treatment may not 
inappropriately be here considered, viz: the possibility, practi- 
cability, and advisability of converting occipito-posterior into 
occipito-anterior positions. The experience of ourselves, as well 
as others, thoroughly convinces us of the possibility of so doing. 
Whether, in all cases, it is an advisable thing is another matter. 
We believe, however, that when the head is still free above the 
superior strait, it may nearly always be accomplished by manip- 
ulation of the suitable kind. But sometimes, in order to ac- 
complish it, the effort involves a certain amount of risk to the 
woman, which it is not always advisable to incur. 

Smellie, more than a century ago, executed such a change in 
a difficult case, and thereby accomplished a result which " gave 
him great joy." The feasibility of the operation is advocated 
by a goodly number of obstetricians of to-day. It is not an 
operation, however, which can be performed at every stage of 

* Martel. " De l'accommodation en obste'trique," quotation p. 93. 
t " System of Midwifery," Am. Ed., 1873, p. 301. 



CAPUT SUCCEDANEUM. 353 

labor, but the possibility of its successful execution is limited to 
two periods, viz: that of early labor, when the head is still free 
above the pelvic brim, and that part of the second stage, when 
the advancing occiput presses firmly on the pelvic floor. At no 
other time should it be attempted. Attention to the ordinary 
movements of the head will sometimes obviate any necessity for 
interference. In the process of descent there is sometimes 
manifested a tendency of the chin to leave the sternum, and the 
head to be extended. To allow this condition to persist, is to 
preclude the possibility of rotation forwards of the occiput by 
the natural forces; while to enforce flexion is the only thing re- 
quired to secure the desired end. In other cases, two fingers 
under the occiput, and slight traction in an anterior or lateral 
direction, during, as well as between, pains, will bring about 
rotation. 

But in other cases, while the head still lies above the brim, or 
but loosely engaged, it is deemed advisable to effect rotation. 
That being true, the forceps may be used, or not. Rotation with 
the forceps will be considered when we come to speak of forceps 
delivery in occipito-posterior positions. Dr. Jno. S. Parry * is a 
strong advocate of manual rotation in these positions. He rec- 
ommends the introduction of the well-oiled hand into the vagina, 
and the fingers through the os uteri. The head is then grasped 
as firmly as possible, and rotation effected, while with the oppo- 
site hand, by external manipulation, the body is rotated on its 
longitudinal axis. The range of applicability of such treatment 
should be left to the good judgment of each individual practi- 
tioner. 

Caput Succedaneum. — This is the name of the swelling 
which forms on the foetal head during labor, as the result of 
effused serum or blood, or both, into the tissues of the scalp. 
It is not found on the head of a dead child. 

It forms on that part of the head which is subjected to the 
least pressure, and hence, at first, within the circle of the os 
uteri. As labor advances, the area is extended, and more or less 
modified. Its development is most marked as the head is being 
driven through the pelvic canal. In the first and fourth positions 
the swelling is found on the right, and in the second and third posi- 

* " Am. Jour, of Obs.,' ; vol. viii, p. 138. 



354 



THE MECHANISM OF LABOE. 



tions, on the left parietal bone. In occipito-anterior positions it 

is located more posteriorly than in occipito-posterior positions. 

Configurations of the Head in Tertex Presentations. — 

The head of the foetus undergoes during labor a considerable 
amount of moulding, by means of which the respective diame- 
ters are greatly modified. The smaller the parturient canal — 
the more difficult the labor, — the more extensive the change. 

The most important modification is the diminution of the 
sub-occipito-bregmatic, the occipito-frontal and the bi-temporal 
diameters, with elongation of what is generally regarded as the 
occipito-mental diameter, but which is, more accurately, the 
diameter represented by a line drawn from the end of the chin 
to a point on the vertex between the anterior and posterior 
fontanelles, nearer the latter than the former. 

Moulding is favored by the existence of fontanelles, the nature 
and width of the commissures, the depressibility of the occiput 
and frontis, and the mobility of the bones at their several artic- 
ulations. As the result of pressure, the frontal bone recedes 
beneath the parietal bones, the occipital bone is pushed forward 
under the parietal, and, finally, one parietal bone laps over the 
other. Moreover, the parietal bones themselves are somewhat 
changed in form, the cranial vault being curved at the point in 
front of the posterior f ontanel'le, hereinbefore alluded to, the 
Fig. 154. Fig. 155. 




Outlines showing difference between head at birth (Fig. 154.), and four days 
subsequently (Fig. 155.) 

sharpness of the curve being determined by the closeness of the 
labor, or, in other words, by the amount of compression exerted. 



FORM OF HEAD IN VERTEX PRESENTATION. 



355 



When the head passes the outlet in an occipito-posterior posi- 
tion, the changes noted, are still more marked. 

The outline* of the head is still further changed by the forma- 
tion of the caput succedaneum. 

Fig. 156. 

We may here add that this long- 
drawn-out appearance of the head, in 
general soon passes away without the 
adoption of any special treatment to 
correct it; but the change may be 
somewhat accelerated, and perhaps, 
rendered more pronounced, by gentle 
pressure upon the poles of the occip- 
itofrontal diameter with the palms of 
the hands. 

Diagnosis of Positions, etc.— 

This subject has been discussed in 

Form of the head in vertex another place, and does not here re- 
presentation, quire mention. 




CHAPTEE VII. 

The Mechanism of Labor.— (Continued.) 

Face Presentations. — The face constitutes the presenting 
part once in about 250 cases.* Churchill's statistics make it 
occur a little of tener. 

Character of Labor. — Labor in connection with face presen- 
tation, while it may, in quite a proportion of instances, be ter- 
minated by the natural efforts, is generally far more tedious and 
difficult than in vertex presentations, and often presents conipli- 



* Charpentier. " Contributions a re"tude des presentation de la lace." p. 15. 



356 



THE MECHANISM OF LABOB. 



cations of a most formidable nature. This is particularly true, 
as will later be seen, in connection with mento-posterior posi- 
tions. For these reasons, and the additional fact that it is a 
presentation in which the dangers to both mother and child are 
considerably increased, we have thought best to adopt the classi- 
fication which places it among abnormal presentations. 

Causes. — There seems to be but little doubt that a large share of 
face presentations are transformed vertex presentations. The 
movement by which the latter is converted into the former con- 
sists only in extension, and a variety of causes may operate to 
effect the change. Hecker * attributes many cases of face pre- 
sentation to unusual length of the occiput, and the theory 
appears to be a plausible one. Other causes of extension are 
set down, as enlargement of the thyroid gland; increased size of 
the chest preventing sufficient flexion of the head; and unusual 
mobility of the foetus, owing to small dimensions. 

Lateral obliquity of the foetus and long uterine axis, are sup- 
Fro. 157. 




Face presentation at the outlet, mento-posterior position. 

posed by many to be an important factor in the etiology of these 
presentations. Uterine action presses the head against the 

* " Ueber die Schadelform bei Gesichtslagen ." 



FACE PRESENTATION. 357 

lateral boundary of the pelvic brim, and tilts it backwards. 
When once extension passes the line of equipoise, the presenta- 
tion becomes permanently established. Proper flexion of the 
head may be prevented by the presence of a prolapsed extremity 
which encroaches upon the pelvic space. 

When, in lateral uterine obliquity, the dorsum of the foetus 
corresponds with the lower surface, the propelling force con- 
stantly increases the tendency to cephalic extension. 

Relative Frequency of Positions. — Statistics are not yet suffi- 
ciently numerous to settle the question of the relative frequency 
of the various positions. There is doubtless but little difference 
in point of frequency between left and right dorsal positions. 
Naegele considered the first as the most frequent, in the ratio of 
twenty-two to seventeen. Tyler Smith says that the "third and 
fourth facial positions are so extremely rare as hardly to be 
worth enumerating." There is, however, quite a lack of harmony 
among obstetric writers, for Leishman and others proclaim the 
fourth position as the most frequent. It is by no means rare for 
the face to enter the pelvis, with its long diameter lying trans- 
versely. 

Mechanism of the First Position of the Face.— In the first 
position of the face the occipito-mental diameter lies in the right 
oblique of the pelvis, and the chin is directed to the right sacro- 
iliac synchondrosis. 

For descriptive purposes we may divide the mechanism of face 
presentations into the movements which follow: 

First movements — descent and extension. 

Second movement — rotation. 

Third movement — flexion. 

Fourth movements — restitution and external rotation. 

These we shall proceed to consider in the order of their occur- 
rence in the first, or right mento-posterior position. 

Descent and Extension. — These two movements, because of 
their almost simultaneous occurrence, are described together 
here, as were descent and flexion in vertex presentations. So far 
as the mechanism of labor is concerned, the chin in face presen- 
tations corresponds to the occiput in vertex presentations, and 
hence in well-marked instances of the former, we find the chin 
sinking lower and lower in the cavity, thereby greatly augment- 



358 



THE MECHANISM OF LABOB. 



ing the extension. The degree of extension is ascertained by 
the relative situation of the chin and anterior fontanelle, both of 
which can generally be reached. The head engages the superior 
strait against mechanical disadvantages, and hence slowly. The 
degree of descent which may be accomplished with some degree 
of facility, is determined by the length of the child's neck, unless 
the thorax and shoulders chance to be small enough to permit 
them to pass into the cavity. 

The chin maintains its advanced position, owing to a mechan- 
ism similar to that which causes the occiput to take the most ad- 
vanced position in vertex presentation. The fronto-mental diam- 
eter represents a lever with the short arm on the mental side, 
and the long arm on the frontal side. Force is applied from 
above, and of course the short arm descends. 

Rotation. — The exact amount of descent which the length of 
the neck will permit in these cases, depends upon the circum- 

Fig. 158. 




Engagement of the head in face presentation (Tarnier et Chantreuil.) 
stances. Experience teaches, that in most cases, the shoulders do 



FACE PRESENTATION. 



359 



not reach the brim and engage it, until after the face presses on 
the perineum. Farther descent is impeded, and rotation for- 
ward of the chin, seems to be a necessity. In nearly all cases 
the movement does take place in a natural manner, and menacing 
dangers are thereby averted. The chin in face presentations, 
and the occiput in vertex presentations, in the movement of rota- 
tion, act in obedience to a similar mechanism. The chin, being 
in advance, first comes in contact with resistance at the pelvic 
floor, and acting under the well-known law of mechanics, that a 
body subjected to various degrees of pressure, moves in the di- 
rection of least pressure, turns forward, while the cranial vault 
seeks the sacral hollow. 

Fig. 159. 




Mechanism of face presentation, first position. (Schultze. J 
In the course of rotation there is a complete change of posi- 
tion, the first becoming the fourth. By means of rotation the 
chin is brought to the pubic arch, and expulsion thereby facili- 
tated. 

Abnormal Mechanism. — In a small percentage of cases, the 
chin, instead of pushing forward to the pubic arch, moves back- 
ward into the sacral hollow, and labor terminates as represented 
in figure 157. The effect of this is excessive stretching of the 



360 THE MECHANISM OF LABOE. 

neck of the foetus, and of the vulvar structures of the woman. 
Unless the child happens to be relatively small, labor can scarce- 
ly be terminated at all, without artificial aid. 

The depth of the pelvis posteriorly, and the added length of 
the perineum, will not admit of descent of the chin over the pos- 
terior vulvar commissure, without a surprising amount of cranial 
flattening, and the entrance of the thorax to a certain extent into 
the pelvic cavity. Cases have occurred in which, from unusual 
smallness of the head, distension of the sacro-sciatic ligaments 
has permitted flexion to take place, and delivery thus to be 
effected. 

Flexion. — In face presentation, the movement by which the 
head passes the vulva is one of flexion. The chin engages under 
the pubic arch, and remains fixed, while the forehead, vertex 
and occiput, successively sweep over the distended perineum. 
Then occurs the final movement, — that of restitution, or external 
rotation, the face in the first position turning towards the moth- 
er's right thigh. The shoulders follow, and expulsion is speed- 
ily accomplished. 

Form of the Cranium in Face Presentation.— As the result of 
excessive compression of the head in so unnatural a position, the 
cranial vault is considerably flattened. The transverse, the occip- 
ito-frontal ,and especially the occipito-mental diameters, are conse- 
quently increased, while the sub-occipito-bregmatic is diminished. 
The tumefaction of the presenting area is liable to be excessive, 
so that the foetal countenance immediately post-partum presents 
an appearance scarcely human. Swelling is greatest in the 
malar region. 

Prognosis. — We have before alluded to the augmented danger 
to both mother and child in this variety of presentation. 
Winckel * gives the mortality of the foetuses in face presentation 
at thirteen per cent., and that of the mothers at six per cent. 
According to the same author, the average duration of labor does 
not greatly exceed that in the vertex presentations^ but protrac- 
tion is attended by more dangerous consequences, and demands, 
with greater urgency and frequency, the aid of obstetric re- 
sources. 

* " Pathologie'der Geburtshiilfe," p. 89. 
fBerichte," Bd. iii, p. 315. 



FACE PRESENTATION. 



361 



The Second Position. — The mechanism of the second posi- 
tion is quite like that of the first, except that the directions are 
changed. Eotation takes place by the chin swinging around 
from the left ilio-sacral synchondrosis to the pubic arch. In 
making the movement the second rotates into the third position, 
from which point onwards the mechanism is essentially that of 
the third. 

Third and Fourth Positions.— The first and second are re- 
cognized as unfavorable positions, because the chin is directed 

Fig. 160. 




Mento-anterior termination of face presentation. 

backwards, and the necessary rotation is extensive. The third 
and fourth positions are favorable, because they are mento-ante- 
rior positions, and the necessary rotation is but slight. In the 



362 THE MECHANISM OF LABOE. 

latter, the chin, in its descent, strikes against one of the anterior 
inclined planes, and is directed forward under the pubic arch; 
while in the former, even though the chin does usually rotate 
anteriorly, much delay and difficulty are often experienced. A 
backward rotation of the chin gives a termination the most un- 
favorable. 

Special detailed description of the mechanism of labor in the 
third and fourth positions is not required, as it differs not at all 
froin that of the second and first positions, respectively, after 
partial rotation has taken place. 

Treatment. — The older obstetricians not only looked upon 
presentations of the face as abnormal, but they deemed artificial 
assistance necessary in ail cases, the treatment being version, 
when practicable, and instrumental delivery in neglected cases. 

An important concern of treatment is to preserve intact, 
throughout the first stage, the bag of waters. This here is a 
matter of more importance than in vertex presentation, because 
of the irregularity of the presenting part, and the likelihood of 
complete escape of the liquor amnii should rupture take place. 

Conversion of Face Into Vertex Presentations.— This is a 
matter worthy the closest attention. The manipulations gen- 
erally recommended are pushing up the face, or drawing down 
the occiput, by means of the hand passed into the vagina and 
cervical canal. Still the suggestion has not often been acted 
upon, owing to the difficulties and dangers accompanying it. 
That it may be done without much effort in favorable cases, the 
author has, from experience, become convinced. There is, how- 
ever, a considerable variation among cases in the call for such 
interference. ^\Vhen the face presents in the first or second po- 
sition, we have an unfavorable condition. In other words, we 
have an undesirable position of an undesirable presentation, and 
by flexing the head we convert the case into a desirable position 
(occipitoanterior) of a desirable presentation, and the measure 
of advantage to be derived from the change would compensate 
for considerable effort and risk. On the other hand, the third 
and fourth positions of the face are favorable positions of an 
unfavorable presentation, and by flexing the head we would con- 
vert them into an undesirable position (occipito-posterior) of a 
desirable presentation, and we would not be justified in assum- 
ing the risk of a protracted or difficult manipulation. 






CONVERSION OF FACE INTO VERTEX PRESENTATION. 



363 



No attempt to change the presentation should be undertaken 
after the head fairly engages the brim, unless delivery by any 
other method seems impracticable, as the occipito-mental di_ 
ameter of the standard foetal head exceeds every pelvic diameter, 
and incarceration would be likely to result. 

In some cases, by firm pressure, the head, even after some de- 
scent has taken place, may be dislodged, and carried above the 
brim, where flexion can be enforced. 

Whenever such manual operations are performed the woman 
should be under the relaxing influence of an anesthetic. 

The following method of manipulation, suggested by Schatz,* 
will sometimes be preferable. We are directed to restore the 
body to its normal attitude by flexing the trunk, when, we are 
told, the head will drop into its normal position in the brim of 
the pelvis. To thus operate, we should seize the shoulder and 
breast through the abdominal walls, and lift them upward, and 
at the same time backward, while, with the opposite hand, we 
steady the breech so as to make the long foetal axis correspond 
to the uterine axis. Finally, the breech and shoulders, or tho- 
rax, are made to approach by downward pressure on the former. 



Fig. 161 



Fig. 162. 




Diagrams illustrating Schatz's method of converting face into vertex presen- 
tations. 

Raising the body, as described, gives the occiput an opportunity 

*"Die Umwandlung von Gesichtslage," etc., "Arch. f. Gynaefcj" Bd. v., p. 
313. 



364 



THE MECHANISM OF LABOK. 



to descend, and flexion of the fcetal body, accompanied by back- 
ward and upward pressure on the chest, produces flexion of the 
head. Schatz says that when the head lies high, any attempt to 
enforce flexion by repression of the thorax, sometimes causes 
movement of the whole head, for want of resistance, and, in such 
cases, the place of the pelvic wall may be supplied by pressure 
of the hand against the head through the abdominal walls. The 
conditions friendly to the practice of this manoeuvre are skill in 
palpation, and the absence of abdominal and uterine irritability. 
When the Face Does Not Enter the Brim. — When the face 
refuses to pass the superior strait, operative interference is indi- 
cated. The character of the aid given will be determined by 
the circumstances of the case. The head may be flexed by 
Schatz's method, or by the introduction of the hand into the 
vagina and cervix, and the face thereby converted into a ver- 
tex presentation; or podalic version may be practiced. In either 
case, the internal manipulation should be aided by dextrous ex- 
ternal use of the opposite hand. Application of the forceps to 
the face at the brim, is, in the main, impracticable and hazard- 
ous, as the blades cannot well be applied to the sides of the 
head, and to seize the face over the poles of its long diameter is 
extremely dangerous to foetal life, from the pressure of one 
blade on the throat, and compression of the large vessels and 
nerves of the part. 

Persistent Mento-posterior Positions.— Tardy rotation ap- 
pears to be characteristic of face presentation, and a fair oppor- 
tunity should be given the nat- 
ural forces. The mechanical 
condition most favorable to for- 
ward rotation of the chin here 
is firm extension, and by main- 
taining it, we greatly augment 
the probability of its occurrence. 
The movement may be aided to 
a certain extent by suitably di- 
rected pressure against the fore- 
head. If these simple methods 
prove ineffectual, the forceps may 
be applied, and the head care- 
fully turned in the direction 



Fig. 164. 




Mento-posterior termination of 
labor. 



BBOW PBESENTATION. 



365 



which it should take. If the long curved forceps be used, 
they will require removal and reapplication for completion of 
the movement. Every effort to bring forward the chin should 
be attempted during a pain. 

Very strong support of the perineum, while favorable to pres- 
ervation of that part, is dangerous to the child, from pressure of 
the neck against the pubic arch. 

Brow Presentation. — When only partial extension takes 
place, the brow becomes the presenting part. Such presentations 
must always be looked upon as of a most unfavorable nature, since 
the long diameter presented, is the longest of the cranium. Four 
positions are given, but, as the presentation is exceedingly rare, 
and generally becomes transformed into either a face or a vertex 
presentation, we shall not here describe them. If the head is 
small, and the pelvis roomy, the labor may be finished without 
unusual difficulty or injury to either mother or child. The head 
passes by the cranial vault sweeping forward over the perineum, 
followed by movement of the upper jaw, mouth and chin under 
the symphysis. 

FlG - 165 - Treatment. — T r e a t - 

ment consists first in at- 
tempts to convert the 
presentation into one of 
either the vertex or face. 
Baudelocque's method of 
doing this involves the 
introduction of the whole 
hand, a thing to be avoid- 
ed if possible. Schatz's 
method of operating in 
face presentation may 

here serve equally well. 
Outline of head, brow presentation. (Budin.) The conjo{nt man i pu l a . 

tion, one hand externally, and the fingers of the other in the 
vagina, is sometimes successfully employed. Schatz * recom- 
mends the introduction of two fingers into the child's mouth, 




* " Die Umwandlung von Gesichtslage zu Hinterhauptslage," etc., " Arch. f. 
Gynaek.," Bd. v. p. 328. 



366 THE MECHANISM OF LABOR. 

and traction on the superior maxilla, for the production of a 
face presentation. 



CHAPTEE VIII. 
The Mechanism Of Lahor.— (Continued.) 

Pelvic Presentations. — Under the general designation of pel- 
vic presentation are included all those cases where the pelvis 
precedes the trunk and head of the child in labor. Pelvic pre- 
sentations are divided into those of the breech, knees and feet 
The mechanism of labor, however, is in all these substantially 
one. From the time of Hippocrates until that of Ambrose Pare, 
in the sixteenth century, delivery was regarded as impracticable in 
pelvic presentations, and the rule of treatment was to introduce 
the hand, and turn by the head. 

Frequency of Occurrence. — Breech presentation is met 
in about 45 mature births, while in premature labor and miscar- 
riage it is of common occurrence. The lower extremities pre- 
sent once in about 100 cases. 

Prognosis. — While labor in these presentations is not un- 
usually dangerous to the mother, the perils of the child are greatly 
augmented. The mortality in breech presentations is in the 
proportion of about 1 death in 3| cases, and in footling presen- 
tations 1 death in 2J cases. Pelvic presentations in primiparse 
are attended with an extremely heavy mortality. Eoberton* 
says of footling cases, "I do not remember having saved the 
life of a child when the feet, in a first labor, formed the presen- 
tation." The danger to the mother, in pelvic presentation, is but 
slightly increased. 

Causes of Infantile Mortality.— The chief element of danger 
in these cases is interruption of the foetal circulation by com- 
pression of the cord. The foetus may be destroyed by asphyxia, 
arising also from another cause, namely, premature separation 

, * " Physiology and Disease of Women and Midwifery," p. 457. 



PELVIC PRESENTATION. 367 

of tb e placenta, followed by premature attempts of the foetus to 
resp ire. Compression of the funis is rarely strong enough to 
seriously interfere with the foetal circulation, until the pelvis and 
most of the trunk have passed the vulva, and the bony cranium 
presses it firmly against the pelvic walls. Premature separa- 
tion of the placenta occurs as the result of contraction of the 
uterus upon the descending head. 

Delay of birth of the head is occasioned by insufficient dilata- 
tion of the soft parts, the trunk not requiring as great expansion 
of the os uteri and vulva, as does the head. 

Danger to the child is not confined to the moment when the 
head lies at the brim, but compression of the cord may take 
place at a later period, and premature separation of the placenta 
is more likely to be effected after the head descends into the 
pelvic cavity, but refuses to pass the vulva. Foetal circulation 
is interrupted, and respiration is impossible, as a result of which, 
death from asphyxia soon ensues. 

Etiology of Pelvic Presentations.— It was supposed by the 
older physicians, that the foetus sat upright in the womb until 
the sixth or seventh month, at which time there occurred a sud- 
den overturning, as the result of which the head became the 
presenting part, and accordingly, breech presentation resulted 
from the non-occurrence of the acrobatic feat mentioned. 
There is no doubt that breech presentation is sometimes the re- 
sult of a peculiarity in the conformation of the uterus. Velpeau 
mentions the case of a woman, who probably from such cause, 
had six consecutive breech deliveries. Pelvic deformity is also 
a causative factor. In a case reported by Dr. Randolph Wins- 
low,* a colored woman, with a deformity of the pelvic brim, had 
ten children, every one of whom presented by the breech. 

Diagnosis. — Nothing need here be said with reference to 
diagnosis, as the matter has been fully discussed elsewhere. 

The Mechanism of Breech Presentations in the First and 
Second Positions. — The first position of the breech is also 
known as the left dorso-anterior position, and is one of the most 
favorable. The breech dilates the os uteri with almost the same 
facility as does the head. 

*"Am. Jour. Med. Sciences," April 1880, p. 444. 



368 



THE MECHANISM OF LABOB, 



Descent* — After the os is so widely expanded as to permit 
the breech to pass, under the forcible propulsive action it sinks 
to the pelvic floor, and approaches the vulva. Descent usually 
progresses but slowly, and dilatation of the os uteri and vagina 
is not required to be great, in order that the trunk may pro- 
ceed on its way. 

Rotation. — There is no ex- 
tensive rotation in the pelvic 
cavity, associated with breech 
presentation. In the first po- 
sition the left trochanter lies 
forward and to the right, and> 
in rotation, it turns from the 
right to the pubic arch. In 
the second position the right 
trochanter lies forward and to 
the left, and, in rotation, it 
merely comes to the pubic 
arch. These are both dorso- 
anterior positions. In the 
third position, the right tro- 
chanter lies forward and to 
the right, and in the fourth 
the left trochanter lies forward and to the left. Eotation in the 
former position is' from right to left, and in the latter 
from left to right; but in no case is the distance traversed 
extensi-ve. And then, too, rotation, insignificant as it is, does 
not often take place until the nates are pushing through the 
vulva, and is only completed when the trunk has nearly passed. 
From inattention to the proper management of such cases, the 
after-coming head may be permitted to descend, and enter the 
pelvis m an occipito-posterior position, when cephalic rotation, 
under unfavorable conditions, becomes necessary. 

Expulsion. — The anterior natis makes its appearance at the 
vulva, and the posterior pushes over the perineum. The ante- 
rior trochanter finds a point of support undei the pubic arch 
until the opposite trochanter passes, when both descend, in a 
forward direction, necessitating considerable flexion of the body 
in the pelvic canal. As the trunk passes, it is well to have the 




First Position of "the Breech. 



BEEECH PEESENTATION. 



369 



fingers ready at the yulva to hook down the arms, which are 
prone to be thrown upwards. The anterior shoulder rests under 
the pubic arch until the posterior passes, and the head only 
then remains. 

Fig. 167. 




Expulsion of the Trunk in Breech Presentation. 

The head engages the brim in an oblique diameter, and usu- 
ally with the chin upon the sternum. The inclined planes turn 
the occiput forward as the head descends. The neck rests in 
the pubic arch, and serves as a centre of motion, and as the 
body is raised by the accoucheur, the face and sinciput pass the 
distended perineum and the second stage is closed. 

The Mechanism of Breech Presentation in the Third and 
Fourth Positions. — So far as the trunk and extremities of the 
child are concerned, there is little difference between the mechan- 
ism of dorso-anterior, and that of dorso-posterior, positions. The 
chief particular in which they deviate has reference to the after- 
coming head. After expulsion of the trunk of the foetus, we are 
apt, in neglected cases, to find that the head engages the brim 
"with the occiput directed to one ilio-sacral synchondrosis, or the 



370 



THE MECHANISM OF LABOR. 



other, and extensive rotation in the pelvic cavity is necessitated, 
which, by the way, is often attended with some difficulty. This 



Fig. 168. 




Birth of the Shoulders. 

is a complication of labor which may be obviated by proper 
attention to the body in its descent through the outlet. When 
the trunk and shoulders are of usual size, there is seldom any 
necessity for close approach of the bis-acromial diameter to the 
pelvic conjugate, at the outlet. Bearing in mind this fact, if we 
will but rotate the trunk on its longitudinal axis during the mo- 
ment of its expulsion, the head, which still lies perfectly free 
above the brim, will also rotate in compliance with the sugges- 
tion thus offered, and as a consequence, this part enters the brim in 
an occipito-anterior position. The rotation here advised should 



BREECH PRESENTATION. 



371 



Fig. 169. 




be neither rapid nor forcible; though we are often obliged to 
accelerate the movement to a certain extent, on account of the 
rapid progress of expulsion. 

In those cases wherein, from a 
combination of circumstances 
beyond the physician's control, 
the head enters the brim in an 
occipito-posterior position, if 
traction is not applied to the 
trunk, the condition of head flex- 
ion will usually be maintained 
by the contracting uterus, and 
rotation will take place in re- 
sponse to slight suggestions from 
the fingers of the accoucheur. 
But this movement, and that al- 
so of final expulsion, depends to 
a very great extent on thorough 
flexion of the head on the breast, 
and the physician should en- 
Third Position of the Breech. f Qrce it by proper manipulation. 

The trunk of the child, wrapped in a towel, should rest upon the 
most convenient arm, while the fingers of the same hand are pass- 
ed into the vagina, as far as the child's face. Pressure and trac- 
tion should then be made with the fingers in the canine 
fossae, while at the same time the fingers of the opposite hand 
exert upward and backward pressure on the occiput, and the body 
is carried well forward, as in all cases of pelvic presentation, 
until the head passes. If the fossae caninae cannot at first be 
reached, the fingers may be passed into the mouth, and traction 
and pressure made on the inferior maxilla. This will answer 
very well in those cases where the foetal head and the pelvic 
canal are in relative proportion; but in difficult cases, while the 
fingers of one hand enforce flexion of the head, those of the 
other must exert traction on the child's shoulders. 

In some cases it may be found impossible to bring forward 
the occiput, and labor terminates with the occiput to the peri- 
neum, and the face to the pubes. There is the same necessity 
here, as elsewhere, for firm flexion of the head, and while en- 
forcing it in the mannei already described, the body should be 



372 



THE MECHANISM OF LABOR. 



carried backward, instead of forward, until, as the neck rests on 
the posterior vulvar commissure, the face revolves about it as a 
centre, and glides under the pubic arch. 



Fig. 170. 




Showing the Completion of Rotation, and Extraction of the Head. 

Footling Presentation. — It is unnecessary to give a detailed 
account of presentations of the feet, since they agree in all es- 
sential particulars with the mechanism of breech presentation. 
Kotation is delayed until the breech reaches the outlet. The 
head is delivered with greater difficulty than in the presentation 
of the breech, since the foetus enters and passes the pelvis, in 
footling cases, in the form of a wedge, with the small end in, 
advance. 



FORM OF HEAD IN PELVIC PRESENTATION. 



373 



Fig. 171. 




Treatment of the Arms.— Ordinarily, the physician experi- 
ences but little trouble in bringing down the arms when they 
are extended upward by the side of the head, but occasionally 

the movement is not easily 
accomplished. The fingers of 
the operator should be passed 
under the pubic arch, and 
over the anterior shoulder, 
when the arm should be made 
to descend over the anterior 
surface of the child. 

Breathing Space for the 
Foetus in Cases of Head 
Retention.— When the head 
cannot at once be delivered 
from the pelvic cavity, and 
the child is making efforts ai 
respiration, the mouth may 
be drawn well down to the 
perineum by means of the fin- 
gers, and then an assistant may admit air to the foetus by in- 
serting two fingers, and making forcible retraction of the peri- 
neum and recto-vaginal septum. By this expedient, more than 
one life has been saved. 

Forceps to the After-Coming Head. — Some strongly con- 
demn the use of the forceps for the purpose of extracting the 
after-coming head; but there is no question that in some cases 
they are of real service. They should always be applied along 
the ventral surface of the child. 

Configuration of the Head in Pelvic Delivery.— The ab- 
sence of long-continued compression of the head in pelvic presen- 
tation, leaves the part in a shape which differs greatly from that 
observed in vertex and face cases. Instead of the long-drawn-out 
appearance given it when the vertex is in advance, we have a 
characteristic roundness, due in part, as is believed,* to its cir- 
cumferential compression by the pelvic canal, while absence of 
decided resistance above, increases the convexity of the cranial 

* Spiegelberg. " Lehrbuchr de Geburtshulfe," p. 176. 



Presentation of the Feet. 






374 



THE MECHANISM OF LABOR. 



vault. Still, the shape of the head usually observed in pelvic 
cases probably approximates the original form of the part. 

Management of Pelvic Presentations.— The practice of 
Hippocrates, and his followers, of converting breech into ce- 
phalic presentations, was succeeded by that of bringing down 
the feet. This mode of treatment is now regarded as not only 
undesirable, but, under ordinary circumstances, unwarrantable. 
We should allow a breech presentation to continue as such, and 

Fig. 172. 




Shape of the Head in Breech Presentation. 

C. D. (Bi-parietal diameter. 

O. F. Occipito-frontal diameter. 

not make the case still less auspicious by converting it into a 
footling presentation. If the labor is proceeding but slowly, 
the temptation may be strong to provide ourselves with a part 
upon which to make traction, and hasten delivery. But the wise 
man withholds his hand. After expulsion has gone so far that 
the trunk of the foetus is partially born, we may feel a strong 
impulse to seize upon it and hasten the labor. But such inter- 
ference with the natural phenomena and mechanism of pelvic 
presentations would be liable to involve us in a labarynth of 
troubles, growing out of the extension of the arms above the 
head, and a separation of the chin from the breast, with its lodge- 
ment above the pelvic brim. When any traction effort whatever 
is made, it should be carefully done, and ought to be supple- 
mented by abdominal pressure. 



TRANSVERSE PRESENTATIONS. 375 

The Question of Cephalic Tersion.— Some have advised at- 
tempts to produce cephalic version by external manipulation; 
but since it can rarely be successfully practiced, and the neces- 
sary effort is liable to rupture the membranes too early and do 
injury to the mother, we believe it an unwise procedure. 

Expulsion of the Trunk. — As expulsion of the trunk takes 
place, it may be received into a dry cloth, which has the double 
advantage of providing warmth for the child, and a better hold 
for the physician. As soon as the umbilicus is reached, the cord 
should be drawn gently down, and carefully felt from time to 
time. If pulsation in it continues good, delivery need not be 
accelerated, but if it should fail, extraction must be hastened as 
rapidly as possible. 

Extraction of the Head. — The manner of effecting this has 
been before suggested. The child, wrapped in a towel, should 
rest on the most convenient arm, and the fingers on the canine 
fossae enforcing flexion. Unless delivery is easily effected, an 
assistant may make firm compression on the fundus uteri, while 
the woman is urged to make her best endeavor. The body must 
be carried well forward, if the case is occipito-anterior, and 
well backward if occipito-posterior, with gentle traction. Flex- 
ion of the head at the outlet, in occipito-anterior positions, is 
sometimes better effected through the rectum. Expulsion of 
the head may also be facilitated by the fingers in the rectum. 

Operative Measures. — Operative measures for relief will be 
considered under the head of "Operative Midwifery," and 
nothing need here be said on the subject. 



CHAPTEE IX. 

The Mechanism of Labor — (Continued.) 

Transverse Presentation. — In transverse presentation we 
have the longitudinal axis of the foetal oval lying across the 
uterus, constituting a most unnatural and unavoidable case. 
Varieties of transverse presentations have been described by 
some writers, such as ventral, and dorsal, as well as shoulder 



376 



THE MECHANISM OF LABOK. 



and arm. The fact is, that in the early stage of labor, almost 
any part of the trunk may constitute the presenting part; but 
experience has taught that no matter what portion of the trunk 
may lie over the os uteri at the beginning of labor, as the case 

Fig. 173. 




Ventral Presentation, 
advances, the shoulder or arm is quite apt to descend, and con- 
stitute the presentation. Hence, in our remarks on the mechan- 
ism of transverse presentations, what is said of shoulder and 
arm presentations is substantially true of other forms of trans- 
verse cases, and we shall accordingly limit our observations 
thereto. 

Frequency. — According to the statistics gathered by Dr. 
Churchill, the arm or shoulder presents once in 231f cases. It 
is much more frequently observed in multiparas than in primip- 
arse. 

The Yarious Positions.— The positions of the foetus in 
shoulder presentation have been described in another place, and 
they do not need to be reviewed here. For purposes of treat. 



TRANSVERSE PRESENTATIONS. 



877 



ment it is highly important that we distinguish them, as other- 
wise we cannot act intelligently. 

Causes. — The causes of transverse presentation are not alto- 
gether clear. Any circumstance which may occur at the brim 
to divert the head from its usual place, and turn it into one of 
the iliac fossae, constitutes an efficient cause; and this may con- 
sist of a pelvic deformity; an unusual quantity of liquor amnii, 
giving to the uterus a form more nearly spherical ; obliquity of 

FrG. 174. 




Anterior half of uterus removed, showing foetus in transverse presentation 
within the membranes. 

the long uterine axis; or premature expulsive efforts. The great 
preponderance of transverse presentations among pluriparae, 
would certainly give color to the theory of Wigand, that the 
phenomenon is dependent on the form of the uterine cavity, 
which is probably changed so that its transverse diameter is 



378 



THE MECHANISM OF LABOR. 



augmented, while its longitudinal measurement is diminished. 
As to the time of its occurrence, it seems probable that in 
some cases it takes place by a sudden movement, during, or at 
the beginning of expulsive efforts; while in other instances its 
existence is known to have preceded labor by days or weeks. 

Diagnosis. — The diagnosis of transverse presentation has 
been considered, in a general way, in another place; but a few 
observations may here be added. Abdominal palpation can 
scarcely fail to reveal the transverse direction of the long axis 
of the foetal oval. The enlargement is relatively broad, while 
the fundus uteri is really below the height at which it is usually 
found in cephalic and pelvic presentations. Deep palpation 
also reveals the head in the iliac fossa. On vaginal examination 
the presenting part lies unusually high, and in some cases, at 
the beginning of labor can scarcely be reached. The stetho- 
scope affords some aid. "If," says Cazeaux, "the vaginal 
Fig. 175. examination has resulted 

in the recognition of a por- 
tion of the foetus which is 
of small bulk, and if we 
perceive the pulsation of 
the heart in the hypogas- 
tric region, we may almost 
certainly conclude that it 
is the superior extremity. 
If we heard the heart at 
the level of the umbilicus, 
it would in all probability 
be a leg." If the position 
is a dorso-posterior one, we 
will probably be unable to 
hear these sounds. 

Prognosis. — In any case, the danger to both mother and child 
is considerably augmented. The prognosis, however, will be 
greatly modified by the stage of labor at which the case comes 
under observation. From carefully collected statistics, tabu- 
lated by Churchill, it appears that " out of 314 cases of presen- 
tation of the superior extremities, 175 children were lost, or 
rather more than one half. Out of 282 cases, 30 mothers were 




Dorso-anterior position of the foetus 
transverse presentation. 



SPONTANEOUS EVOLUTION AND EXPULSION, 



379 




Dorso-postenor position of the foetus in 
transverse presentation. 



lost, or nearly 1 in 9." Statistics of more recent practice would 
probably show a slight reduction in the rate of mortality. 

Spontaneous Evolution. 
—Spontaneous E x p u 1 - 
sion. — Symptoms. — Dr. 

Kigby has given a graphic 
picture of a case of trans- 
verse presentation when 
unassisted. " After the 
membranes have burst," 
says he, "and discharged 
more liquor amnii than in 
general when the head or 
nates presents, the uterus 
contracts tighter around 
the child, and the shoulder 
is gradually pressed deep- 
er in the pelvis, while the pains increase considerably in 
violence from the child being unable, from its faulty position, 
to yield to the expulsive efforts of nature. Drained of its liquor 
amnii, the uterus remains in its state of contraction even during 
the intervals of the pains; the consequence of this general and 
continued pressure is, that the child is destroyed from the circu- 
lation in the placenta being interrupted, the mother becomes ex- 
hausted, and inflammation and rupture of the uterus and vagina 
are the almost unavoidable results." 

So far as the mother is concerned the early part of labor ap- 
pears to be natural and favorable: but after a time, varying in 
different cases, the symptoms of powerless labor supervene, and 
unless aid is afforded, or unless the child is relatively small, or 
has become putrid, the woman will sink, and die undelivered. 

Transversa presentations differ from the others before de- 
scribed, in having no regular and uniform mechanism of labor; 
but there are two movements occasionally observed, by virtue of 
which nature has succeeded in concluding the process of partu- 
rition; these are spontaneous version or evolution, and what was 
designated by Douglas as spontaneous expulsion. Both these 
occurrences are extremely rare. 
Spontaneous evolution or version, consists in a complete ver- 



380 THE MECHANISM OF LABOE. 

sion of the foetus, begun by the escape of the shoulder from the 
grasp of the pelvic brim, followed by descent of the trunk, and 
finally the pelvis of the child. This process is not nearly so 
frequently observed, as that of spontaneous expulsion, first de- 
scribed by Dr. Douglas, of Dublin. In this the shoulder does 

Fig. 177. 




Showing a case of transverse presentation wherein the liqnoramnii has escaped, 
the arm has descended, and the shoulder is wedged into the brim. 

not recede from the brim, and give place to other parts, but it 
descends until it rests under the pubic arch, where it is arrested, 
and constitutes a centre upon which the body of the child 
revolves, version thereby occurring within the pelvic cavity. "It 
will be obvious," says Leishman,* " that such a mechanism as 
this can only be possible under the same exceptional conditions 
which permit of spontaneous evolution. For in this case the 

* Leishman, loc. tit p. 337. 



TEEATMENT OF TRANSVEESE PRESENTATION. 



381 



breech must pass the pelvic brim, which is already partly occu- 
pied with the base of the skull — an occurrence which is mani- 
festly impossible, if the relative proportion of the parts, mater- 
nal and foetal, are in accordance with the normal standard. 

Fig. 178. 




Spontaneous expulsion, from a frozen specimen, by Chiara. 

The various stages of this important movement are made 
more explicit by the accompanying cuts, than could be done by 
any number of words. 

Treatment. — In connection with the question of treatment, 
no one point is of such importance as a recognition of the char- 
acter of the case at the earliest possible moment. This involves, 
too, not a mere diagnosis of transverse presentation, but a rec- 
ognition, as well, of the position occupied by the foetus, for upon 
this the success of treatment will largely depend. When such 
knowledge is obtained at the beginning of labor, or soon there- 
after, we may look upon the case with composure, knowing that 
the issue lies in great measure under our control. Both moth- 
er and child are still possessed of unimpaired vitality, and the 
aim of our treatment will be to interfere before the life forces 
have seriously suffered. 

The Favorable Moment for Operating.— There comes in all 
these cases a moment which may be regarded as opportune, and 



382 THE MECHANISM OP LABOE. 

nerves and the muscles of even those minions of obstetric for- 
tune, to whose superlative skill all difficulties give way." 

If the arm and hand have prolapsed, no attempt should be 
made to replace them before proceeding to operate. The woman 
should be carefully brought under the influence of an anaes- 
thetic, not only to prevent suffering, but to allay the irritability 
of the uterus, which would interfere with a speedy and relative- 
ly easy accomplishment of our purposes. The details of the 
operation will be given in another place. The necessity for the 
utmost gentleness and caution should be kept constantly in 
mind, for "wombs and women are not to be taken by assault." 

A thrust of the hand here is as fatal as a thrust of the 
bayonet. 

Death of the Foetus. — If the physician, on being called to a 
case of shoulder presentation, find clear evidence of foetal 
death, he will be led to adopt a different method of treatment, 
and one less hazardous to the woman. The signs in question are 
a flaccid, pulseless cord, if it can be felt, and exfoliation of the 
skin as the result of incipient putrefaction. Evisceration is the 
treatment for such a case. 

Unaided Termination. — In many rare cases it may be obvi- 
ous that labor is about to be terminated by nature, through one of 
the movements previously described. During a pain, the child 
is observed to move m such a way as clearly to reveal its design 
to eflect either spontaneous evolution or expulsion. Under such 
circumstances, the expectant plan of treatment is the proper. 
"If the arm of the foetus," says Douglas, " should be almost 
entirely protruded, with the shoulder pressing on the perineum; 
if a considerable portion of its thorax be in the hollow of the 
sacrum, with the axilla low in the pelvis ; if, with this disposi- 
tion, the uterine efforts be still powerful, and if the thorax be 
forced sensibly lower during the pressure of each successive 
pain, the evolution may, with great confidence, be expected." 

Other Operative Procedures.— When all other' means have 
failed to effect delivery, and when, in other cases, the foetus is 
certainly dead, it may be decapitated, it may be eviscerated, or 
it may be delivered through abdominal incision. 

Complex Presentations. — The most common forms of pres- 
entation, and even some of the uncommon varieties, have been 



TREATMENT OF TRANSVERSE PRESENTATION. 383 

A method of delivery in transverse presentation has been prac- 
ticed with success in a number of instances by Dr. K. Ludlam, 
which consists of the knee-elbow position, cephalic version, and 

Fig. 180. 




Spontaneous expulsion (second stage.) 

the application of the forceps. The cephalic version is greatly 
facilitated by the knee-elbow position, since the force of gravity 
diminishes the pressure upon the brim, and places the child in 
a more mobile situation. When once the cephalic version is 
effected, the forceps are applied, with the woman still on her 
knees and elbows, though perhaps not with the greatest facil- 
ity. She is then permitted to resume the supine position, and 
delivery is at once effected. What was a formidable case, is from 
that time forward an ordinary delivery with the forceps. 

The form of version recommended by most authorities is the 
internal podalic, which consists in the introduction of the hand 
within the uterus, and the bringing down of the feet. The con- 
ditions favorable for the performance of this operation are, an 
intact state of the membranes, and dilatability, or dilatation, of 
the os uteri. As the labor progresses in the first stage, it should 
be attentively watched, and, if the membranes are preserved, 
and no serious symptoms are developed, we may safely await 



384 THE MECHANISM OF LABOR. 

with patience, the moment of nearly complete dilatation. Should 
the waters sooner escape, provided the os uteri is as large as a 
half-dollar, and in a dilatable state, the operation should be un- 
dertaken without unnecessary delay. 

The feet may sometimes be brought to the os uteri by the 
method of conjoint manipulation, so highly recommended by 
some. It is clearly the preferable mode, if the case is a suita- 
ble one for its practice, as an operation, in the performance of 
which only two fingers, instead of the whole hand, are intro- 
duced, must involve less risk than necessarily attends the ordi- 
nary procedure of drawing down the feet. Hence, unless the 
conditions which surround the case offer no encouragement 
whatever, it is advisable at first to attempt to effect our purpose 
by the conjoint method, and, if that fails, we may then have re- 
course to the more common method. Conjoint efforts should be 
put forth as soon as the os uteri will admit two fingers, as delay 
beyond that time progressively diminishes the chances of 
success. 

But there is a class of cases quite different from these, in re- 
gard to which apprehension will arise, and in the treatment of 
which great difficulty will be experienced. "Though always 
more or less dangerous," says Blundell,* in his earnest, eloquent 
way, "the operation of turning may often be accomplished 
easily enough, provided it be performed early enough, and cir- 
cumstances conduce. Hence you will sometimes hear your ob- 
stetric acquaintances triumphantly exclaiming — * For my part, I 
always turn without any difficulty;' a declaration, by the way, 
which evinces not their superior skill, but their small experience 
in the nicer and more dangerous parts of practice. In consul- 
tation, especially, we sometimes meet with cases of turning — 
embarrassed at once with difficulties and dangers; the body of 
the uterus is constricted about the foetus; the mouth and cervix 
are more or less firmly contracted around the presenting part; 
the passages are swelled, inflamed, and dreadfully irritable; the 
patient, wearied with exertion, and desperate through suffering, 
cannot be persuaded to lie at rest upon the bed; and thus, some- 
times, though rarely, a case is treated which might try the 

* <l Lectures on the Principles and Practice of Midwifery." 1842, p. 155. 



TREATMENT OF TRANSVERSE PRESENTATION. 



385 



happy the accoucheur who discriminates it with exactitude, and 
is prepared to apply the suitable treatment with a vigorous hand, 
and wise judgment. 

Fig. 179. 




Spontaneous expulsion (first stage. 



Preservation of the Membranes.— It is of the utmost impor- 
tance that the membranes be preserved intact up to the moment 
of interference. This consideration will lead to careful vaginal 
explorations, avoiding the moment of uterine contraction, and 
anything more than moderate pressure on the bag of waters. 

Tersion. — Some form of version is required in all such pre- 
sentations, save in rare and neglected cases, wherein the expul- 
sive action has gone so far as to destroy all reasonable prospect 
of success. 

The various methods of practicing version will be discussed 
in another chapter. We are only called upon here to indicate 
the varieties of version which are applicable to transverse pre- 
sentations. Cephalic version, or a bringing down of the head, 
is suitable to some cases, and, under favorable conditions, will 
scarcely fail of success. This is best practiced by Dr. Braxtoa 
Hick's method of conjoint manipulation. 



386 THE MECHANISM OF LABOB. 

mentioned; but there are others of rare, though possible occur- 
rence, wherein the presentation is compound in character, as, for 
example, when the hands and feet descend together. Most 
complex presentations are modifications of transverse positions, 
while in some, the long foetal and long uterine axes maintain 
their parallelism. A description of one or two of them will be 
briefly given. 

Hand with the Head. — This is not an uncommon occur- 
rence, especially when the foetus is relatively small as compared 
with the pelvic canal. Labor will not become seriously imped- 
ed, provided the hand be prevented from descending to any ex- 
tent. Even in those cases in which the arm becomes extended 
by the side of the head, labor generally terminates in a satis- 
factory manner; but should the head chance to be relatively 
large, the labor may be extremely diflicult. 

The suitable treatment consists in pushing up the arm, so as 
to obviate the compression which is otherwise liable to ensue. 
In affording such relief, however, we should be careful not to 
displace it backwards, and thereby produce a still more awk- 
ward condition of things. 

The Feet and Hands. — Both feet and both hands may pre- 
sent, or but one of each, and thereby form a variety of trans- 
verse presentation. The complication is sometimes still further 
increased by prolapse of the umbilical cord. Left to the natu- 
ral efforts, the foot, or feet, after a time, are likely to recede, and 
a shoulder to descend; or the presentation may not change, but 
be driven downward, and finally wedged into the brim. To pre- 
vent such an occurrence, the foot, or feet, should be seized, and 
drawn down, while the hand is pushed upward, thereby com- 
pleting the operation of version at the expense of but a slight 
effort. If this is undertaken early in labor, no great difficulty 
will be experienced; but when attempted at a late period it may 
utterly fail, or, at best, be accomplished as the reward of a 
strenuous effort. In the latter class of cases, a fillet should be 
attached by a running noose above the ankle, and persistent 
traction made upon it, while the hand is pushed upward, and, 
by abdominal manipulation, the version aided. If such a pres- 
entation is rendered still more complicated by descent of the 
funis, an attempt should be made to send it back into the uter- 



COMPLEX PRESENTATIONS. 



387 



ine cavity with the presentii*g, but now receding, hand and arm, 
failing in which, the case will be treated as one of prolapsed 
funis with footling presentation. Both the reposition of the 
cord, and the completion of version, will be favored by putting 
the woman into the knee-elbow position. 

Fig. 181. 




The use of the ill let with a running noose. 

Head, Hand and Foot — The head, hand and foot have been 
found presenting together, and there has even been added pro- 
lapse of the cord, a condition represented in the accompanying 
cut. 

Fig. 182. 




Presentation ot head, hand, foot and funis. 



; 



388 ANOMALIES OF THE EXCELLENT FOKCES. 

Version is here again a necessity, and it should be undertaken 
at the earliest practicable moment. 

Other forms of complex presentation might be mentioned, but 
to do so would be useless, as their treatment is in accordance 
with the principles already laid down. 

Prognosis in Complex Presentations. — Any form of pre- 
sentation which involves the performance of so serious an ope- 
ration as podalic version, is always attended with increased risk 
to both mother and child. The fatality obviously depends in 
great measure upon the period or stage of the parturient act at 
which interference is practiced. 



CHAPTEE IX. 

Labor Rendered Difficult or Dangerous by 
Anomalies of the Expellent Forces. 

In those cases wherein the natural forces are adequate to over- 
come the resistance usually offered by the soft parts, or the bony 
pelvis, labor is physiological. It may be rendered pathological 
by a variety of anomalous conditions having reference to the 
expellent forces, the parts through which the foetus must pass, 
the foetus itself, as well as certain extrinsic elements which 
enter as disturbing elements. 

Viewed from a clinical standpoint, we judge of pains (contrac- 
tions ) by the effects which they produce ; but in practice we find 
it convenient to consider them in connection with their effects on 
the duration of labor, and accordingly we have 1. Precipitate 
labor, and 2. Protracted labor. 

In no two cases of labor do we observe the same conditions 
and phenomena. Sudden and decisive changes occur at various 
stages of what may be regarded as ordinary cases. For exam- 
ple ■ up to a certain point, a labor may progress with the utmost 
regularity and facility, when suddenly the expulsive forces lan- 
guish, and progress is at once arrested. On the other hand a 



PRECIPITATE LABOR. 389 

tardy action may be suddenly superseded by accelerated move- 
ment, and the final expulsion be precipitate. 

Precipitate Labor. — There are several degrees of precipitate 
labor. In its milder forms it is generally attended with but 
slight inconvenience, and as little danger; but there are cases in 
which the contractions are so powerful, vehement, frequent, and 
uncontrollable, as to result in serious traumatism of the perine- 
um, cervix uteri, and the body of the womb itself. The foe- 
tus traverses the parturient canal with such rapidity as to 
fall on the street, or the floor, into the chamber-vessel or the 
closet bowl. In such cases the suffering endures but for a brief 
season, but it is so redoubled in severity as sometimes to pro- 
duce convulsions, apoplexy, and mania. The fall of the child in 
cases of precipitate labor terminating with the woman in the 
erect position, is usually broken by the cord, laceration of which 
is rarely followed by hemorrhage. The involuntary efforts of 
the woman are sometimes so intense especially when the vul- 
var structures are still unrelaxed, as to cause subcutaneous 
emphysema of the head and neck, to modify the utero-placental 
circulation, and even to fracture the foetal skull, as well as to 
result in lacerations of the tissues in and about the vulva. 

The following remedies may be given, but we hardly have 
time to get their action, in many instances, before labor is 
brought to a close. Chloroform may, very properly, be admin- 
istered to diminish the vehemence of uterine and abdominal 
action. 

Excessively severe labor pains, coffea, nux vomica. 

Labor pains too prolonged and powerful, secale. 

Uterine Inertia, Weak Labor. — In some women there is a 
lack of tone in nerve and muscular fibre which exercises a 
marked influence on the character of the labor. " In women, 
moreover," says Leishman,* " of this temperament, the ana- 
tomical peculiarities of the sex are generally well marked, and 
the ample and shallow pelvis thus offers a comparatively trifling 
resistance to the passage of the child. If, however, we contrast 
with this the tall, vigorous and muscular women, we find that in 
the latter there is a very general tendency to the male type of 

* Loe tit., p. 566. 



390 ANOMALIES OF THE EXPELLENT FOKCES. 

pelvis, involving a tardy passage of the child through the pelvic 
canal. May we not infer that it is in some degree in compensation 
for this that she is furnished with muscles so powerful, and con- 
stitutional vigor so marked, to enable her to overcome the greater 
resistance which in a feebler frame would constitute an insur- 
mountable barrier." 

We might with propriety include under the head of tedious, 
or prolonged labor, all cases wherein the expulsion of the foetus 
is unusually delayed, from whatever cause the delay may arise; 
but in this place we shall speak only of labor protracted from 
causes referable to deficient uterine force. 

The average duration of labor is from eight to ten hours, the 
latter for primiparse, and the former for multipara. Labor may 
be weak from the very beginning, or, as we have hinted, inertia 
may suddenly develop in a case which, up to near the close of 
the second stage, has been vigorous and active. 

Causes. — In many cases inertia of the uterus is the result of 
over-exertion during a protracted first and early second stage, 
it being an expression of the complete exhaustion from which 
the woman suffers. In a large number of instances it proceeds 
from general debility, the woman's health having been impaired 
by acute or chronic disease, or her general tone lowered by con- 
stitutional feebleness. Rapid child bearing doubtless has a 
marked effect in the same direction. Excessive and premature 
uterine retraction is an efficient cause in quite a percentage of 
cases; and also adhesions of the membranes to the lower uterine 
segment. High temperature of the surrounding atmosphere 
such as we get in the middle of a hot summer, also has a de- 
pressing effect. Sudden and profound emotions, in the instance 
of a sensitive woman are sometimes capable of weakening the 
pains, or even of entirely suppressing them, though such 
causes do not often maintain their action for a lengthened period. 
Over distension of the bladder, or rectum, and a condition of 
inflammation in the abdominal viscera, may be reckoned among 
the causes of this complication of labor. Hydramnios should 
also be mentioned, its effects, however, being limited to the first 
stage. The age of the patient has a marked influence. In young 
girls there appears to be a proneness to weak and irregular uter- 



WEAK LABOK. 391 

ine action, and in those nearing the close of the child-bearing 
period, powerless labor is by no means an infrequent occurrence. 

Symptoms.— Weak labor is manifested in the first stage by short 
and inefficient pains. They are often near together, but they 
scarcely develop force before they cease. The os does not expand 
as it ought, and the woman becomes nervous and despondent. 
Irregular action is liable to ensue to increase the difficulties and 
painfulness of the labor. 

During the second stage, labor may become inert. Perhaps, 
while the head lies at the very outlet, the pains grow ineffi- 
cient, and lose their expulsive character. From the fact that the 
perineum in some of these cases seems unyielding, delay is too 
often attributed to that condition; but good pains speedily dis- 
pose of such a state. 

Inertia of the uterus may continue even into the third stage, 
and thereby complicate placental delivery, as well as give rise to 
profuse and dangerous post-partum hemorrhage. 

Treatment. — The character of treatment will be controlled by 
the stage of labor in which the inertia manifests itself, and the 
cause of the occurrence. The condition of the bladder and rec- 
tum should be investigated; the mental state and age of the 
woman considered; and the character of the presentation, and 
state of the uterus, as regards retraction, passed under review. 
When it evidently depends on excess of liquor amnii, unless 
there are contra indications, the membranes may be ruptured, 
and a part of the fluid permitted to escape. Adhesions of the 
membranes to the lower uterine segment should be broken up 
by sweeping the finger about within the os uteri. A warm vaginal 
injection will sometimes promote uterine contraction, favor the 
physiological changes in the cervix, and mechanically distend 
the vagina. Barnes' bags are of service, but far better, and 
more effective, we believe is manual dilatation of the os, prac- 
ticed with the utmost gentleness. 

The following suggestion with regard to preventive treatment 
of these cases should be remembered: — "The moment we find 
the least evidence of flagging power," says Dr. Edis,* "of any 

*" Obstet. Jour." Vol. vii, p. 236. 



392 ANOMALIES OF THE EXPELLENT FORCES. 

cessation of pains, any intermittence in the regular beat, or any 
acceleration of the patient's pulse, or any general evidence of 
the patient having had more than she can fairly compass, I think 
we are bound in duty to assist the patient, and not allow her to 
go on until she is in powerless labor." 

In protracted second stage, resulting from inefficient uterine 
action, expression may occasionally be effected, but aside from 
homoeopathic remedies, our main reliance must be placed on the 
forceps. Ergot will sometimes afford efficient, and, we believe, 
harmless aid; but if the weak labor is the result of premature, 
or excessive, uterine retraction, the unfavorable conditions will 
be aggravated by it. If administered at all, the force, frequency 
and regularity of the foetal heart ought to be watched by means 
of the stethoxope, and, should these indicate a serious disturb- 
ance of the vital force, the forceps should at once be applied. 

When the head, in cases of uterine atony, lies at the outlet, it 
may usually be expelled by means of two fingers, or the thumb, 
in the rectum, combined with abdominal pressure. 

Therapeutics. — Inefficient — Labor-pains violent, and fre- 
quent, but inefficient: aconite. 

Labor-pains too weak, but regular: cethusia. 

Labor-pains violent, but inefficient: arnica. 

Labor-pains tormenting, but useless, in the beginning of labor: 
caulophyllum. 

Labor-pains short, irregular, spasmodic, patient very weak, 
no progress made: caulophyllum. 

Labor-pains spasmodic and irregular: cocculus. 

Labor-pains spasmodic: causticum, ferrum, pulsatilla. 

Labor-pains spasmodic, cutting across from left to right, nau- 
sea, clutching about the navel: ipecac. 

Labor-pains spasmodic, painful but ineffectual: platina. 

Labor-pains spasmodic, they exhaust her greatly: stannum. 

Labor-pains spasmodic and distressing, patient irritable: 
chamomilla. 

Labor-pains distressing, but of little use; cutting pains across 
abdomen: phosphorus. 

Labor-pains ineffectual, of a tearing, distressing character, 
seemingly not properly located: actaia. 



WEAK LABOR. 393 

Labor-pains severe, but not efficacious; she weeps and laments: 
coffea. 

Weak, False, Deficient — Labor-pains weak or ceasing; she 
wants to change position often; feels bruised: arnica. 

Labor-pains weak or ceasing; she will not be eovered; restless; 
skin cold', camphor a. 

Labor-pains deficient or absent; she has only slight periodical 
pressure on the sacrum; amniotic fluid gone, os uteri spasmod- 
ically closed: belladonna. 

Labor-pains weak or ceasing, with great debility, especially 
after violent disease, or loss of animal fluids: carbo veg. 

Labor-pains become weak, flagging, from protracted labor, 
causing exhaustion; patient thirsty, feverish: caulophyllum. 

Labor-pains cease from loss of blood: china. 

Labor-pains ceasing, with complaining loquacity: coffea. 

Labor-pains gone, os widely dilated, complete atony : gelsem- 
ium. 

Labor-pains weak, accompanied with anguish and sweat, and 
desire to be rubbed: natram mur. 

Labor-pains spasmodic, irregular; drowsiness: natrum mur. 

Labor-pains deficient, irregular, sluggish: Pulsatilla. 

Labor-pains deficient, with os soft, pliable, dilatable : usiilago. 

Labor-pains suppressed, or too weak: secale. 

Labor-pains cease, coma, retention of stool and urine — from 
fright: opium. 

Labor-pains cease, or become weak, from anger: chamomilla 
colocynth. 

Labor-pains cease from excessive grief: ignaiia. 

The Forceps in Inert Labor. — There is occasion for the ut- 
most discretion in the use of the forceps in cases of weak labor 
proceeding from real uterine atony. We should here distin- 
guish between the latter condition and that of premature, or ex- 
cessive uterine retraction. In the latter instance, the instru- 
ments are not only called for, but there is little, if any danger, 
attending their use. The same cannot be said of the former 
condition. The head has descended into the pelvic cavity under 
the influence of fair pains; but, after a time, advancement ceases, 
the pains become feeble, and the case comes to a halt. Long 
delay under such circumstances is not free from serious danger 



394 ANOMALIES OF THE EXPELLENT FORCES. 

to the woman, owing to continuous compression of the soft pelvic 
tissues. Recourse is had, perhaps, to various well-indicated 
remedies, without relief. The uterine energies are still too 
broken to respond. After a time the forceps are applied, and 
the delivery finished without difficulty; but, we find that the 
uterus, instead of assuming its usual cannon-ball contraction, 
remains weak and sluggish, with the effect to develop an aggra- 
vated attack of post-partum hemorrhage. The danger, then, in 
all such cases is, that the atony, with which the uterus is stricken, 
will continue, and excessive bleeding result. There is little dan- 
ger of such an occurrence in connection with labor rendered 
weak by the premature, or excessive, retraction of the uterus 
alluded to above. 

Now, if even moderate action of the organ is renewed by the 
remedies administered, and the stimulus applied, we may cau- 
tiously proceed with our forceps delivery. For, unless a com- 
plete atony exists,the very introduction of the instrument commu- 
nicates a stimulus of the most effective kind, so that our traction 
efforts are often found to be reinforced by uterine action. Bear- 
ing in mind the dangers which are most liable to arise, we for- 
tify ourselves against them by adopting such precautions as are 
described in connection with the prophylactic treatment of 
post-partum hemorrhage. 

Treatment of the Third Stage of Labor Complicated by 
Uterine Inertia. — The great danger which is associated with 
uterine weakness in the third stage of labor, is that of post-par- 
tum hemorrhage. A sluggish uterus in this stage is always the 
cause of much anxiety. Hemorrhage may set in early, immedi- 
ately succeeding placental delivery, or it may not appear at all. 
There should be no haste to deliver the placenta, and, above all, 
no traction should be made on the cord. With the hand firmly 
grasping the organ through the abdominal walls, we should for 
a time maintain an expectant attitude, unless bleeding sets in. 
We must watch and wait. Upon the supervention of profuse 
flow, or upon the occurrence of a uterine contraction, the pla- 
cental mass can be expelled by Crede's method, and the uterus 
afterward firmly held. Under such precautions as these, should 
the treatment of the third stage of powerless labor be con- 
ducted. 



WEAK LABOR. 395 

With a weak third stage is often asssociated irregular uterine 
contraction, as a result of which there may be a constriction of 
part of the organ, most frequently at one of its angles, but often 
at or near the site of the internal os, with firm retention of the 
placenta. Relaxation of the structure usually takes place spon- 
taneously, but it may sometimes be hastened by the administra- 
tion of the suitable remedy. Belladonna, gelsemium, or cuprum 
are indicated in a general way, and our choice between them 
will be based on the special symptoms observed. Chamomilla 
is indicated when the woman is irritable, thirsty, and restless. 
Cocciilus has also been found serviceable. The inhalation of a 
few drops of amyl nitrite will sometimes relax the spasm. Un- 
der no circumstances should such a patient be left, until the pla- 
centa has been delivered; for the muscular fibres of the body of 
the uterus may relax before those of the lower segment, and give 
rise to hemorrhage. The forcible reduction of an irregular con- 
traction of the uterus should not be undertaken soon after de- 
livery, unless alarming hemorrhage sets in. Patient waiting, 
and careful prescribing, will usually bring about the desirable 
result. After a reasonable time, however, a gentle endeavor 
may be made to get away the placenta, and the plan to be fol- 
lowed is thus stated by Lusk:* "The plan I have followed of 
late years, with uniform success, consists in introducing the in- 
dex and middle fingers, with the whole hand in the vagina, to 
the point of constriction. Then, by pressing the uterus down- 
ward, the fingers are brought in contact with the placental bor- 
der. Now, it is only necessary to draw a single cotyledon 
into the canal to render the further extraction a matter of cer- 
tainty. Under the pressure of the soft, placental mass, the 
stricture relaxes slowly. By combining expression with slight 
traction, the delivery is surely accomplished. The principal 
difficulty of the operation lies in the manipulations needful to 
bring the placenta at the outset to the point of stricture, but 
this difficulty can be pretty certainly overcome by patience and 
the determination to succeed. During the period of withdrawal 
the operator should be content with a very slow progression, 
proportioned to the yielding of the tissues; otherwise the pre- 
senting portion of the placenta tears away, when the labor ex- 
pended is lost." 

*" The Science and Art of Midwifery," p. 430. 



396 LABOR OBSTRUCTED BY MATERNAL SOFT PARTS. 



CHAPTEE XL 

Labor Obstructed by Maternal Soft Parts. 

Among the most common obstructions to labor from faulty con- 
ditions of the soft parts of the mother, the following may be 
named: Rigidity of the os and cervix uteri, arising from vari- 
ous causes; agglutination and obliteration of the cervical canal; 
contractions and obstructions of the vagina; rigidity of the 
perineum; thrombus of the vagina and vulva; vesical and rectal 
distension; uterine polypoid growths; ovarian and fibroid tumors. 

Rigidity of the Cervix Uteri. — Rigidity of the cervix arises 
from different causes, and is dependent on various pathological 
conditions. 

1. It may come from incompletion of the physiological pro- 
cess of softening, which takes place during pregnancy, and 
is usually more or less pronounced in every case of premature 
labor. 

2. Abnormal rigidity of the os externum is often encountered 
in multipara as the result of genuine cicatricial processes. 

3. Fibrous hypertrophy of the cervical body is occasionally 
met. This condition is especially observed in connection with 
prolapse of the uterus. 

4. Carcinoma of the cervix, as mentioned in another place, 
gives rise to most persistent rigidity. 

5. In aged primiparge, atrophic degenerative changes in the 
cervical tissues, or hypertrophy of the portio-vaginalis, make 
the os reluctant to yield. 

6. A certain degree of rigidity of the cervix is observed in 
connection with general tonicity and firmness of tissue, espe- 
cially in young and robust primiparse. 

7. Last of all, we have a condition vastly more common than 
any of the others, and which is most frequently signified when 



RIGID OS UTERI. 397 

the term "rigid os" is employed; we mean a spastic state of the 
circular fibres of the cervix; a trismus of the part; spasmodic 
rigidity. The others are instances of mere passive rigidity, or 
non-dilatability. 

Generally speaking, it is an occurrence which exists quite in- 
dependently of any diseased condition of the parts, and is, in 
fact, a purely functional lesion. It is found in various degrees 
of intensity, from that which causes but slight delay, to the 
more aggravated forms which yield unwillingly to the measures 
adopted for their subjugation. 

Symptoms. — In the more obstinate cases of the spasmodic 
form, the os either refuses to dilate at all, or expansion advances 
to the size of a silver half-dollar or dollar, and remains un- 
changed for hours, or, in badly managed cases, even days, in a 
thin, hard and unyielding condition, notwithstanding the force 
exerted by the longitudinal and oblique fibres of the uterus to 
overcome it. It occurs most frequently in premature labor, 
when the cervix and lower segment of the uterus have not com- 
pleted their physiological, changes. It is commonly associated 
also with malpresentations. In some instances the lips of the 
os become cedematous and hypertrophied, and to the finger seem 
thick and tough, but the undilatability remains. The cedema- 
tous condition alluded to occurs most frequently in stout pleth- 
oric women, at a time when the pressure by the head has been 
long continued, especially after escape of the liquor amnii. It 
should not be confounded with a condition, somewhat similar, 
which is often observed in multipara during the progress of 
dilatation. 

This form of rigidity owes its origin to constitutional pecul- 
iarities, more especially a highly-nervous and emotional tem- 
perament, which can scarcely bear the ordinary pains of labor. 
The sufferings of a woman during the period in which her cervix 
uteri is in a state of rigidity, are often of the greatest intensity, 
just as in every tonic spasm of muscles in other parts of the 
body. Madam Lachapelle considered pain in the loins as a 
valuable diagnostic sign of this condition. "It would appear 
from reports, that, in the practice of some, labor is com- 
plicated by rigidity of the os uteri in quite a large percentage 
of cases. Young practitioners are especially liable to such 



398 LABOR OBSTRUCTED BY MATERNAL SOFT PARTS. 

experiences. But, right here they fall into error, and upon 
this wise: They make an examination per vaginam during 
a pain, and find the os uteri with hard and rigid lips. 
'Surely,' they say, 'this must be a rigid os,' and they so re- 
gard it. Had they tested the condition of the part during the 
interval between contractions, it would have been found pliable, 
perhaps to a marked degree."* 

After the pains have continued for a long time without much, 
or any, progress of dilatation, they begin to lose their vigor; the 
patient's tongue becomes spread with a dry, brownish coating, 
the skin hot, the pulse rapid, and the vagina and cervix hot and 
dry. Such symptoms are hastened by a dry birth, whether the 
waters have escaped through spasmodic or artificial rupture of 
the membranes. 

Further consideration is given most of the other forms of 
rigid os uteri a little further on. 

Treatment. — Immediate danger is not to be apprehended 
from a rigid state of the os uteri, and hence, there is no great 
urgency for more energetic measures than the administration 
of the indicated remedy. Later, if the condition persist, the 
woman may take a hot sitz bath, for a few moments only, or 
a prolonged hot water vaginal enema. In the treatment of old- 
school physicians, opium is here regarded as the most precious 
remedy, and belladonna stands second. 

Molesworth's Dilators, and Barnes' Bags. — When the head 
remains high in the pelvis, and the membranes are unruptured, 
the finger cannot be used to advantage, or the mode of digital 
dilatation described below would be recommended. If our rem- 
edies have failed, it will then be necessary to resort to the 
caoutchouc dilators of either Molesworth or Barnes, to accom- 
plish the necessary expansion. They are provided in different 
sizes. The smaller ones should first be used, and substitu- 
ted by those of larger size as rapidly as the expansion of the 
os will permit. 

Manual Dilatation. — In these cases of spasmodic rigidity of 
the os uteri, digital dilatation may be safely and efficiently prac- 
ticed. It should not be undertaken without first having resorted 

* " The Clinique," vol. ii, p. 397. 



RIGID OS UTERI. 399 

to medicinal aid; but that failing, as sometimes it will, a careful, 
skillful, persistent effort with the fingers will generally accom- 
plish the desired end. Explicit directions are not required; but 
we may say that, so long as dilatation of the os is but slight, we 
can best operate by drawing and pressing on the lips, in various 
directions, when room will soon be made for a second finger, and 
then, by spreading the digits, further dilatation will be secured. 

Incision of the Cervix. — Vaginal Hysterotomy. — If all other 
means fail, as they rarely will, the cervix uteri may be incised 
in its circumference, with a blunt-pointed bistoury, in three or 
four places, to the depth of a quarter of an inch. Afterwards 
the natural efforts will be sufficient to carry on the dilatation, 
or it may be promoted by judicious use of the fingers. 

Use of the Forceps. — It is becoming the practice of the more 
advanced obstetricians to resort to the forceps in certain cases 
of rigid os uteri. Instead of following the old rule to await 
full dilatation before using the instrument, a restriction which 
would exclude the instruments in all these cases, — they resort 
to the forceps in obstinate cases, as soon as the expansion is 
ample enough to admit the blades. The operation is especially 
called for when, as often happens, a rigid os is associated with 
puerperal eclampsia. In some cases it is wise to incise the os 
before applying the instruments. In all cases wherein the for- 
ceps are employed before complete dilatation of the os, the 
greatest care is necessary. The forcible words of Blundell * are 
here appropriate. " The grand error you are apt to commit, in 
using the long forceps, is force. In violent hands, the long for- 
ceps is a tremendous instrument. Force kills the child; force 
bruises the soft parts; force occasions mortifications ; force bursts 
open the neck of the bladder; force crushes the nerves; — beware 
of force, therefore; arte nan vi!" A gentle, cautious, but reso- 
lute effort with the forceps, in cases of rigid os which have re- 
sisted other means, will generally be rewarded with success. 

Craniotomy. — If there is considerable pelvic contraction, or 
when, from other causes, the forceps are inadequate to effect 
delivery, the accoucheur may be driven to the necessity of em- 
ploying that terrible instrument the perforator. Dr. A. K. 

*" Lectures on Midwifery," p. 259. 






400 LABOR OBSTRUCTED BY MATERNAL SOFT PARTS. 

Gardner * gives expression to the following sentiments respect- 
ing the last two operations: "If, therefore," says he, "there be 
any immediate necessity for any obstetric operation, do it irre- 
spective of the local condition; apply the forceps through an 
undilated os; perform craniotomy through abut partially dilated 
os; and even, if necessary, incise the os, in order to render an 
operation practicable." 

Therapeutics. — When the os uteri gets dry and sensitive, 
with spasmodic rigidity, and the woman restless and thirsty, 
aconite is the remedy. 

When the os is hard and unyielding from the irregular muscu- 
lar action alluded to, without other and special indications, the 
remedy which is most likely to afford relief is belladonna. By 
physicians of all schools of practice, this remedy has been re- 
garded with great favor. Its local use has also been recom- 
mended. Airopia, the active principle of belladonna, has also 
been employed, and doubtless in many cases with benefit. It is 
said by some to act with greater precision and energy, when ad- 
ministered hypodermically; and Dr. Henry S. Horton f has de- 
vised a syringe, with hooked needle, for the purpose of injecting 
a solution of atropia into the tissues of the cervix itself. 

The local use of both belladonna and atropia we regard as 
rarely producing desirable results which cannot be obtained 
from the administration of an attenuation by the mouth; while 
poisonous effects are often observed. 

Gelsemium in both attenuation, and fluid extract, or tincture, 
has been found of service in a certain number of cases. By 
some it is carried to the extent of producing toxical effects with- 
out always obtaining relief of the spastic condition. 

Caulophyllum has been highly extolled by others, and there is 
no doubt that it is sometimes a most efficacious remedy. 

When the patient is extremely irritable and restless, chamo- 
milla will often afford relief. 

Uterine Tetanoid Constriction.— It may occasionally hap- 
pen during labor, that progress is impeded by the occurrence of 
a circular tetanoid contraction of a limited portion of the mus- 
cular fibres of the uterus, above the internal os. 

* Vide Glison. " Text Book of Modern Midwifery," p. 364. 
f " Am. Jour. Obs.," vol. ii, p. 362. 



UTERINE TETANOID CONSTRICTION. 401 

Character of the Stricture. — Hosmer likens the stricture to 
a band of metal; Davis says the uterus is "as if a strong rope 
had been tightly drawn around it;" and Gay says, "it felt as 
hard as bone, and at first was mistaken for bone." Dr. Reamy 
says: " Nothing which I had ever encountered in uterine con- 
traction could convey any idea of the power of the constriction." 

Diagnosis. — The stricture may sometimes be made out from 
careful abdominal palpation, but we are liable to confound 
the feel with that of premature and excessive retraction of the 
uterus, mentioned under the head of " Uterine Inertia." It will 
be distinguished from that condition mainly by the general char- 
acters of the labor, which do not point originally to weakness, but 
to obstruction. Then, too, vaginal examination does not reveal 
premature disappearance of the os uteri from retraction over 
the presenting part, though it must be remembered that this 
does not always accompany the anomaly mentioned. 

Treatment. — The operations usually performed to overcome 
obstructions have generally been resorted to, but with most un- 
satisfactory results. Cesarean section itself has been suggested. 
Such cases are rare, and we are not aware of the success which 
has attended the use of homoeopathic remedies in their treat- 
ment, but we should expect good results from belladonna, gelsem- 
ium, caulophyllum, and perhaps aconite. It may be that amyl 
nitrite will prove efficacious. Chloroform has failed to unlock 
the spasm. 

Agglutination of the External Uterine Orifice.— There 

have been but a few cases of this form of obstruction reported. 
It is probably the result of inflammatory action, and has been 
known to occur after cauterization employed for endo-cervicitis. 
Though these adhesions resist firm uterine contractions, and 
constitute a bar to labor, they may be broken up by the finger, 
with a loss of but a few drops of blood. 

Complete Obliteration of the Cervical Canal. — This is an 
extremely rare condition. It differs from simple agglutination 
of the external os, chiefly in the greater strength of the adhesion, 
operative measures being required to overcome it. 

Vaginal hysterotomy is the treatment required. If the site 
of the original opening can be found, an incision should be 
made with a bistoury, in a transverse direction, to the extent of 



402 LABOR OBSTRUCTED BY MATERNAL SOFT PARTS 

half an inch. Or, the uterine tissues may be picked up with a 
pair of toothed forceps, and then divided with scissors. 

Tumefaction and Incarceration of the Anterior Lip. — 

When descent of the head begins, as it frequently does, before 
retraction of the cervical ring has taken place, the anterior lip 
of the os uteri may become compressed and held between the 
head and pubes. This condition usually disappears spontane- 
ously, without becoming excessive; but in occasional instances 
it will require relief. 

Treatment consists in pressing upward the tumefied part, in 
the interval between pains, and maintaining it in a situation 
above the brim, until the head descends far enough to prevent 
its return. Blot mentions a case in which the tumor formed by 
the anterior lip, thus confined, was an inch and a quarter thick, 
and descended to the vulva. The labor had to be terminated 
with the forceps. 

Sanguineous tumors have in some cases resulted, which upon 
rupturing, either during or after labor, have created serious, and 
even alarming, hemorrhages. 

Carcinoma of the Cervix. — The cervix uteri is occasionally 
the seat of cancerous degeneration during the child bearing period, 
and the result is extensive thickening and induration of the 
part. Carcinoma of the cervix, even in an advanced stage, is no 
bar to conception, though it will but occasionally take place; and 
even then manifests a strong tendency to ultimate in foetal 
death and premature expulsion. Pregnancy also causes rapid 
development and progress of the disease. 

Delivery is sometimes absolutely and effectually obstructed, 
especially by the harder forms of the growth. In other cases 
the cervical mass is fissured by the necessary expansion. 

When the intervention of art is demanded, it may be found 
necessary to make repeated incisions on the periphery of the 
cancerous mass. Subsequently the labor may be terminated 
with the forceps, or the case left to the efforts of nature. If, 
after making the incisions, the cervix is still too contracted to 
admit the forceps, — a thing which will but rarely occur, — crani- 
otomy is to be performed. Cazeaux * thinks however, that, so 

* Cazeaux, loc. eit. p. 704. 



THROMBUS OF YULVA AND YAGINA. 403 

far as the mother's risks are concerned, they are about equal in 
craniotomy and Caesarean section; and since the former involves 
certain death to the child, the latter is the preferable operation. 

Cauliflower Tumors of the Cervix. — Such tumors may arise 
from either lip, and by growth, finally cover the os. In the 
practice of M. Nelaton, the internes of Lourcine Hospital mis- 
took a Cauliflower excresence of the cervix, with a pedicle an 
inch and a half long, for an arm presentation, and sent for Nel- 
aton to perform version. 

When these tumors are so large as actually to prevent foetal 
expulsion, they have, in favorable cases, been removed, while in 
others, craniotomy and gastro-hysterotomy have been performed. 

Thrombus of the Yulva and "Vagina.— Effusions of blood 
into the pelvic cellular tissue, and the labia, constitute serious 
complications of labor. In bad cases the effusion is not limited 
to a small area, but it may extend for a considerable distance. 

Prognosis. — The dangers attending this accident of labor, are 
said to be less now than formerly, but b still considerable. Out 
of twenty-two cases reported by Dr. Fordyce Barker, two died; 
and out of fifteen reported by Scanzoni, one died. 

Symptoms. — The accident is usually developed suddenly, and, 
most frequently, toward the close of the second stage of labor, 
or immediately after fcetal expulsion. The woman experiences 
more or less pain, and if the fingers are in the vagina, the forma- 
tion of the tumor is felt, sometimes hard and large like a small 
fcetal head, for which it has been mistaken. Distension may be- 
come so excessive as to produce rupture, attended with consid- 
erable hemorrhage. If much blood is lost, either into the throm- 
bus, or at the site of it, the symptoms commonly attending ex- 
cessive depletion are observed. 

The effused blood, if small in quantity, may be absorbed; if 
greater, there will be rupture, suppuration or sloughing. 

Treatment. — If the thrombus is large, it will act as a formid- 
able obstacle to spontaneous delivery, and, until reduced, may 
even forbid extraction with the forceps. In the latter case, free 
incision should be made across it, and the coagula turned out. 
To arrest the hemorrhage which follows, the wound should be 
packed with styptic cotton, and digital pressure maintained. 



404 



LABOB OBSTBUCTED BY MATEBNAL SOFT PABTS. 



If the thrombus is preserved intact, or first develops after 
delivery, the physician should not hasten to adopt such treat- 
ment; but the expectant plan is then preferable. Eecovery from 
the effects of the accident will be more tardy under such treat- 
ment, but, by adopting it, the dangers of hemorrhage and sep- 
ticaemia are diminished. Contrary opinions are held by some. 
When rupture has occurred, or when the tumor has been incised, 
the resulting wound should be treated under strict antiseptic 
precautions. 

Cystocele sometimes complicates labor, and makes it assume 
serious phases. The bladder, by descent of the head, becomes 

Fig. 183. 




Cut showing cystocele. A represents the prolapsed bladder. 

divided into two compartments, and the lower one is pushed 
downward in advance of the head. This can occur, however, 
only as the result of inattention to proper evacuation of the 



VESICAL CALCULUS. 40§ 

viscus. If the part thus pressed upon is considerably distended, 
and does not receive suitable attention, it may offer decided re- 
sistance, and itself become ruptured. It is maintained by 
some that it is a condition not always chargeable to the medical 
attendant, since occasionally it arises from prolapsus of the 
bladder existing before, and independently of, pregnancy. We 
cannot but feel, nevertheless, that when permitted to seriously 
complicate delivery, the physician is in a high degree culpable, 
as an early vaginal examination ought to reveal the condition, 
and afford an opportunity to remedy it. 

Treatment consists in passing a soft rubber catheter, unless 
compression prevents its use, when a male silver catheter should 
be carefully introduced, with the curve looking toward the va- 
gina. If neither instrument can be successfully used, the dis- 
tended viscus may be punctured per vaginam, with a hypodermic 
needle, or the small needle of an aspirator, and relief thus 
afforded. In such cases there is no rational excuse for failure 
by the adoption of judicious measures to prevent serious obstruc- 
tion, or vesical rupture. 

Impaction of Fceces in the Rectum. — The presence in the 
rectum of hardened foeces may constitute an obstacle to labor. 
Scybalae will be felt through the recto-vaginal septum on making 
a digital examination, and, when detected, should be removed by 
repeated enemata. An accumulation of magnesian deposits in 
women accustomed to take this substance for the relief of heart- 
burn, or as an aperient, is sometimes found. The extreme hard- 
ness may at first give rise to the impression that there is a pelvic 
exostosis, but a careful examination will correct the error. Ob- 
stinate cases may not yield to enemata, but require for their 
removal a process of excavation. 

Rectocele. — The posterior vaginal wall, including the recto- 
vaginal septum, may prolapse during labor, but it can scarcely 
constitute a formidable impediment, unless hardened fcecal ac- 
cumulations are contained in the rectal pouch thus formed. Re- 
moval of such offending matters is usually accomplished with 
facility. 

Yesical Calculus. — This complication of parturition has been 
met in a large number of recorded cases. When the stone is 
large, and it descends before the fcetal head, labor cannot be 



406 LABOR OBSTRUCTED BY MATERNAL SOFT PARTS. 

finished without its spontaneous, or operative, removal. In any- 
neglected case, laceration of the bladder, and vesico-vaginal 
fistula are the almost certain results. 

Diagnosis is readily made, for the stone, from its situation 
and moveable character, cannot easily be mistaken for any other 
contingency of labor. These cases demonstrate the importance 
of timely vaginal examination, for when the presence of the stone 
is early detected, it can generally be passed above the pubes, in 
which situation it is not so apt to produce mischievous results. 
If the labor has advanced too far to admit of such treatment, or 
if the size of the stone is too great, the rule is to perform the 
operation of lythotomy through the vagina. If time and oppor- 
tunity are auspicious, lithotrity is in some cases the preferable 
procedure. 

Diffuse Swelling. — Swelling and tumefaction of the soft parts 
of the parturient canal are liable to complicate expulsion. In 
various forms of obstructed labor, as for example, in deformed 
pelvis, the long continued pressure, and the repeated uterine 
contractions and muscular effort, give rise to the complication. 
A similar condition is sometimes noticed in connection with ordi- 
nary labor, due, probably, to intense hyperemia and irritation. 
If excessive, hot water injections will bring about some reduc- 
tion, but if the bladder and rectum are kept clear, little harm is 
likely to ensue. 

Unyielding Hymen. — As mentioned in another place, women 
occasionally become pregnant through a cribroform hymen, and 
in other cases through one possessing but a single small aper- 
ture, and the structure, owing to its unusual toughness, remain- 
ing unbroken, forms an obstacle to delivery. Left to the natural 
course of events, these membranes, however hard, would proba- 
bly be ruptured by the descending foetus; but more or less delay 
and unnecessary pain would be suffered. It is far better to 
dispose of them by making a crucial incision, before pressure or 
strain has become excessive. It is probably better still, when 
such conditions are recognized during pregnancy, to make the 
necessary incisions at once, as there is no danger, and scarcely 
any pain attending the operation. 

Uterine Polypi Obstructing Labor. — Polypoid growths 
springing from the uterus at the os, the interior of the cervix, 



UTEKINE POLYPI. 407 

or the cavity of the uterus, when they exist in the non-pregnant, 
commonly prevent conception; but there are exceptions to the 
rule. In other cases they are developed, or greatly augmented 
during gestation, and at the beginning of labor emerge from the 
os uteri, and act as impediments to the natural processes. When 
they arise from the lips of the os, they are usually of small 
proportions, and cystic character. Those which spring from the 
interior of the cervix, or corpus uteri, are larger, and of a fibrous 
nature. 

Fig. 184. 




Small polypi of the cervix. 

The uterine contractions are sometimes forcible enough to 
detach them. Unless they are so large and unyielding as to 
constitute a positive bar to delivery, they should not be removed. 
Cystic polypi can be punctured with an aspirator needle, or 
a small trocar, and their contents drawn off. 

It is occasionally possible to push the tumor above the pelvic 
brim, out of the way of the presenting part, as has been demon- 
strated in numerous instances. This is sometimes practicable, 
even where the conditions are extremely unfavorable. Mr. 
Spencer Wells relates a case* wherein he was called to perform 
Csesarean section, but succeeded in pushing the obstructing 
tumor above the brim, when the foetus passed with ease. Per- 
sistent effort, and considerable force, are sometimes required, 
when the impending dangers to both mother and child warrant 
the procedure. Before attempting the operation the woman 
should be deeply anaesthetized. 

If the tumor is hard, and cannot be pushed above the brim, 
the next operations for consideration are enucleation and abla- 

*" Obstet. Trans.," vol ix, p. 73. 



408 



LABOR OBSTRUCTED BY MATERNAL SOFT PARTS. 






tion. Such growths usually have loose attachments, and, when 
within reach, can often be enucleated. If this is impracticable 
they may be twisted off, or removed with the ecraseur. Should 
neither of these operations be deemed expedient, the character 
of further treatment will be determined by the amount of ob- 
struction, the operations in their order being the forceps, crani- 
otomy, and abdominal section. 

Fig. 185. 




Labor impeded Ly a polypus. 

Hemorrhage after delivery has generally been regarded as 
strongly menaced in these cases, but fortunately it is not so 
common as might be expected. 

Tumors of the Ovary Obstructing Delivery.— An ovarian 
tumor of any considerable size cannot descend into the pelvic 
cavity, and hence will not become a serious obstacle to delivery. 
Those tumors which really do encroach upon the space which 



OVABIAN TUMORS. 



409 



forms the parturient canal, are such as have previously attracted 
little or no attention. 

We should distinguish between cysts containing fluid, and 
those with only solid matters. If the character of the tumor is 
doubtful, no serious injury will be inflicted by an exploratory 

Fig. 186. 




Labor obstructed by ovarian tumor. 

puncture with a fine aspirator needle, or small trocar. Playfair 
collected and tabulated fifty-seven cases of ovarian tumor ob- 
structing labor,* with the following results: In thirteen, labor 
was terminated by the unaided natural powers, but, of* this num- 
ber, six mothers died. With these he contrasts nine cases in 
which the tumor was diminished by puncture. The mothers all 
lived, and six out of the nine children were saved. " The rea- 
son," he says, " of the great mortality in the former cases is ap- 
parently the bruising to which the tumor, even when small 
enough to allow the child to be squeezed past it, is necessarily 
subjected. This is extremely apt to set up a fatal form of dif- 
fuse inflammation, the risk of which was long ago pointed out 
by Ashwell, f who draws a comparison between cases in which 
such tumors have been subjected to contusion, and strangulated 



*"Obstet. Trans.," vol. ix. 

f Guy's Hospital Reports, vol. ii. 



410 LABOR OBSTRUCTED BY MATERNAL SOFT PARTS. 

hernia; and the cause of death in both is doubtless very similar. 
This danger is avoided when the tumor is punctured, so as to 
become flattened between the head and the pelvic walls. On this 
account, I think, it should be laid down as a rule, that puncture 
should be performed in all cases of ovarian tumor engaged in 
front of the presenting part, even when it is of so small a size 
as not to preclude the possibility of delivery by the natural 
powers." 

In five of the fifty-seven cases, the tumor was pushed above 
the pelvic brim, and the terminations were in every instance in 
maternal recoverjr. It is a wise procedure in all those cases 
where the contents of the sac cannot be evacuated by puncture, 
to make a persistent, yet not harsh attempt, to return the tumor 
to a situation above the pelvic inlet. Such treatment will some- 
times succeed even in unpromising cases. 

Should both puncture and reposition fail, or be out of the 
question, craniotomy would be preferable to any attempt at de- 
livery with the forceps. In extreme cases, abdominal section 
may be the only mode of extraction. 

Rigidity of the Perineum.— Kigid os uteri has sometimes 
associated with it, and augmenting parturient dangers and dif- 
ficulties, a rigidity of the perineum, which owes its existence to 
a like cause. In most instances, the hardness is gradually over- 
come, and the perineum escapes without serious laceration; but 
sometimes the contraction is unyielding, and rupture the conse- 
quence. In general, the structures of the pelvic floor and out- 
let are softened during labor, by physiological processes, into a 
condition of elasticity and ductility, and the perineum yields be- 
fore the advancing head, to the necessary degree, without much 
solution of continuity. On the contrary, we find that, in some 
instances, such softening does not take place, and, at the ex- 
pense of the integrity of the tissues, the foetus is allowed to pass. 
The latter condition is most frequently observed in primiparae, 
and hence perineal rupture most frequently occurs in first la- 
bors. It is especially true of aged primiparse ; in whom there is 
usually a non-elasticity of the soft structures, uncommon in 
younger women. Old cicatrices, the results of former laceration, 
may impart a firmness again dangerous to its integrity. 

" Rotten" Perineum. — There is much difference in perinea 



RIGID PERINEUM. 411 

as to their ability to withstand a severe strain. Every physician 
of experience has observed that a moderate dilatation will at one 
time cause rupture, while an excessive expansion, in another case, 
will be suffered without accident. Dr. Matthews Duncan says:* 
"There is no doubt in my mind that, in certain cases, there is 
what may be called rottenness of tissue, which destroys the 
power of the tissues to resist laceration or bursting. In some 
women, and occasionally, at least, very markedly in the syphil- 
itic, this condition is very easily demonstrated. It is a condi- 
tion also of many inflamed tissues, and this is exemplified in the 
perineum." 

Treatment. — The ordinary precautions against ruptured 
perineum, described under the head of " management of natural 
labor," need not be repeated here. Nor is there anything to be 
added, for, when we have faithfully applied them, we have done, 
in a protective way, all that ifc is possible for us to do. And the 
physician should not forget that, even when he has so done, his 
patients will occasionally have ruptured perinea. 

Immediate Perineorrhaphy. — The time for operating in 
cases of ruptured perineum has been much discussed, and va- 
rious opinions are still held. It appears however, that the 
weight of testimony is in favor of the immediate operation. 
This consists in thoroughly cleansing the ruptured surfaces, 
and bringing them together at once by strong sutures. The 
results obtained have not been uniform, but these depend 
on a variety of conditions, prominent among which are 
the patient's surroundings, and the precise mode of operation. 
Immediate perineorrhaphy has proven itself unsuited to hospi- 
tal practice, the percentage of failures being very large; but in 
private practice it has been quite otherwise. 

The parts should be thoroughly cleansed with a soft sponge, 
and rags of torn tissue snipped off before they are brought to- 
gether. Silver-wire is preferable for sutures, and the needle 
.should be passed deeply enough to get a firm hold of the flaps. 
Very deep sutures are not required. Three or four to the inch 
should be taken, and after twisting the ends, they should be left 
about half an inch long, and turned backwards so as to prevent 

*" The Obstet. Jour.," vol. iv., p. 45. 



412 LABOR OBSTRUCTED BY MATERNAL SOFT PARTS. 

irritation. The woman should then be placed on her side, with 
the knees padded, and tied together. The urine should be 
drawn three or four times every twenty-four hours, during the 
first five or six days, and the vagina syringed with a mild anti- 
septic solution three times a day. The sutures can be re- 
moved on the fifth day. The best dressing for the wound is a 
soft piece of linen, saturated with dilute calendula tincture. 
When thus treated, the laceration will rarely fail to repair. 

Some obstetricians recommend that even slight ruptures be 
immediately stitched; but we regard such treatment unnecessary, 
alarming to the patient, and gratuitous self -imputation on the 
physician's care and skill. The lacerations generally undergo 
spontaneous repair, if only a little care be bestowed on them. 
In such cases we will do well to follow the old plan of putting 
the woman on her side, bringing the bandage well over the 
thighs, to restrict motion, keeping her there for two or three 
days, meanwhile drawing the urine as often as may be neces- 
sary. We may add to this a pad, nicely fitted to the perineum, 
held in position by a T bandage. The most extensive ruptures 
sometimes spontaneously heal.* 

* Dr. F. D. Lente reported the following interesting case to the N. Y. Obstetri- 
cal Society, ("Am. Jour, of Obs." vol. viii. p. 525.) 

" Some years ago two of my intimate professional acquaintances were inter- 
ested in such an exceptional case. One was the late Prof. Geo. T. Elliot, the 
other Dr. John G. Perry. The vagina of this lady was the smallest and most 
rigid which Dr. E. had ever met with, which led him to caution her friends 
that laceration would probably occur. It became necessary to resort to the 
forceps, and although he used the smallest and lightest in his possession, and 
all the usual skill and care for which he was distinguished, an appalling lacer- 
ation did occur, splitting the sphincter ani, and the vagina throughout its whole 
length to the bottom" of Douglas* cul-de-sac." This laceration though not sewed, 
underwent perfect repair. 



JUSTO-MINOR PELVIS. 413 



CHAPTEE XI. 

Labor Obstructed by Some Unusual Condition 
of the Maternal Osseous Structures, 

Deformities of the Pelvis.— Without following closely the 
usual classification of deformed pelves, we shall consider under 
the above title, deviations from the common form and size, 
whether the dimensions of the pelvic canal are uniformly- 
changed, or are contracted in particular diameters. 

Large Pelvis. — While the difficulties and pains of labor are 
considerably diminished in the case of enlarged pelvis, the dan- 
gers are not correspondingly reduced. Mere facility of expul- 
sion is not the most important consideration in connection with 
labor. When the pelvis is too roomy, dangers and complica- 
tions of a different sort are liable to arise. These are such as 
accompany precipitate labor in general, and consist mainly of a 
dragging or forcing downward of the entire uterus, from want 
of proper resistance of the pelvic walls, and hence rapid disten- 
sion of the soft structures, the occurrence of laceration of the 
cervix uteri, and the perineum. Among the dangers may also 
be mentioned strain and rupture of the cord from sudden expul- 
sion of the foetus with the woman in the erect posture, and also 
uterine inversion. 

Symmetrically Contracted Pelvis, or PelTis iEquahiliter 
Justo-Minor. — The general form of the pelvis may be symmetri- 
cal, the relative diameters remaining unchanged, but the structure 
be small from equable contraction of all its diameters. These 
conditions constitute one of the most formidable obstacles to 
delivery. Fortunately such pelves are rarely met. They pre- 
sent an infantile type, and are doubtless occasioned by prema- 
ture arrest of osseous development. 



414 LABOK OBSTRUCTED BY PELVIC DEFORMITY. 

Flattened Pelvis. — The peculiarity of this form of pelvis is 
its shortened conjugate diameter. The transverse measurement 
remains nearly normal. 

There are two varieties, dependent on the causes which opera- 
ted in their production. The flattened, non-rachitic form is the 
most frequently met. In it the sacrum is depressed and pushed 
inward, between the two ilia. A great degree of contraction is 
uncommon, the conjugate diameter rarely falling below three 
inches. The cause of this deformity is not well understood. 
Lifting and carrying heavy burdens in early childhood, incom- 
pletely developed rickets, and retarded development, in differ- 
ent cases are regarded as sharing in its production. 

Fig. 187. 




The Flattened, (Rachitic) Pelvis. 

In the rachitic form of flattened pelvis the bones are gener- 
erally rather small, but sometimes compact and thickened. The 
ilia are flattened and spread. The sacral promontory is thrown 
inward toward the pubic symphysis, and the base of the sacrum 
depressed between the ilia. The sacrum has a sharp curve for- 
ward, at or about the fourth vertebra. The sacrum also loses 
its side to side curve. The transverse diameter of the brim is 
about normal. The horizontal rami of the pubes are flattened, 
and the acetabula are turned forward. The ischia are spread, 
and hence the pubic arch is widened. Such a pelvis is contract- 
ed at the brim, and widened at the outlet, while its depth is 
diminished. Owing to depression of the sacrum, there is a 
sinking observable in the lumbo-sacral region. 



IBBEGULAB RACHITIC AND MALACOSTEON PELVIS. 415 

The proximate cause of these deformities is traceable mainly 
to the weight of the superimposed body on the pliable bones. 
Some of the changes, however, are probably congenital, some 
due to muscular action, and others to disturbances of growth and 
persistence of the foetal type. 

Flattened, Generally Contracted, Pelvis. — This variety 
closely resembles the justo-minor pelvis, and, during life, is not 
often distinguishable from it. The deformity is most frequently 
due to rachitis. 

Irregnlar Rachitic and Malacosteon Pelvis. — Kickets usu- 
ally comes on before the child has begun to walk, and the weight 
of the body is thrown on the ischia instead of the acitabula. 
Malacosteon begins later in life, and the weight of the whole 
trunk is transmitted to the thigh bones through the acetabula. 
As a result of these varying conditions, a decided difference in 

Fig. 188. 




Malacosteon Pelvis. 

the character of pelvic distortion is observed. The most fre- 
quent of all the varieties of rachitic pelvis is that wherein the 
conjugate diameter of ihe brim is shortened by projection for- 
ward of the sacral promontory, accompanied, or not, by depres- 
sion of the pubes. Different varieties of distortion have been 
described as "masculine," "heart-shaped," and "figure of eight" 
deformities of the brim, all of them, however, preserving the 
general elliptical form. In the malacosteon pelvis the general 



416 



LABOR OBSTRUCTED BY PELVIC DEFORMITY. 



form is angular, occasioned by the depressions at the acetabula, 
growing out of the conditions before mentioned. 

The characters of these two varieties of deformity are oftem 

Fig. 189. 




Isabel Redman's Pelvis. 

blended, as shown in figure 189, which represents the pelvis of 
Isabel Eedman, on whom Dr. Hull performed the Csesarean 
operation, September 22d, 1794 "These are," says Leishman,* 
" mere illustrations of possible variations, which might be infi- 
nitely multiplied; but it is to be remembered that a considerable 
number of cases have been met with in which an undoubtedly 
rickety pelvis presented all the more prominent characteristics 
of malacosteon deformity." He also adds: "In so far as the 
true malacosteon pelvis is concerned, it has been well observed 
by Stanley that there is no diminution in the actual circumfer- 
ential measurement of the brim, and that the bones are of their 
natural bulk and proportion, so that if their various doublings 
were unfolded, the pelvis would be restored to its normal di- 
mensions and form. In rickets, however, this does not usually 
apply, owing, as has already been observed, to the partial arrest 



* "System of Midwifery," Am. Ed.. 1873, p. 434. 



OBLIQUELY CONTBACTED PELVIS. 417 

of development which obtains during the course of the disease." 

Obliquely Contracted Pelvis. — This distortion essentially 
consists in a deficient development and flattening of one side of 
the pelvis, of an anchylosis of the sacro-iliac joint of the same 
side, and of a depression of the sacrum toward the latter, while 
the symphysis pubis is thereby displaced so as to be nearly 
opposite the sacro-iliac synchondrosis of the sound side. 

Flattening of the Sacrum. — A relatively more common form 

Fig. 190. 




Obliquely Distorted Pelvis. 

of pelvic deformity, sometimes associated with other distortions, 
and again existing independently of them, is flattening of the 
sacrum. On account of such a deformity, the head may become 
incarcerated in the pelvic cavity, and occasion much difficulty in 
delivery. 

Exaggerated Curve of the Sacrum. — The opposite condi- 
tion to that just described is occasionally observed, consisting 
of an exaggeration of the sacral curve. 

Funnel- Shaped Pelvis. — What has been termed the "fun- 
nel-shaped" pelvis, in its general appearance bears quite a re- 
semblance to the male pelvis. In such a specimen the diame- 
ters of the pelvic canal diminish from above downward, and the 



418 



LABOB OBSTBUCTED BY PELVIC DEFOBMITY. 



head, when driven into such a pelvis, is liable to become impact- 
ed, and delivery to be attended with considerable difficulty. 

Infantile Type of Pelvis. — From arrest of development, the 
pelvis occasionally preserves its infantile form, presenting a 
greater inclination of the brim, and a relatively great conjugate 
diameter at the brim. 

Fig. 191. Fig. 192. 




Flattening of the Sacrum. Exaggerated Sacral Curve. 

Deformities from Spinal Curvature. — The shape of the 
pelvis is considerably modified by spinal curvature, especially 
in those cases which originate in infancy or childhood. Thus 
kyphosis and scoliosis, both have their peculiar pelvic distor- 
tions. 

Robert's Anchylosed and Transversely Contracted Pel- 
vis.— In this deformity there is bi-lateral sacro-iliac anchylosis, 
and absence or rudimentary development of the sacral lateral 
masses. The sacrum is narrow, especially at the base, and both 
its longitudinal and transverse concavities are nearly or quite 
obliterated. The sacrum is depressed, and the promontory is 
tilted somewhat forward. The ilia are flattened; the descend- 
ing rami of the pubes unite at an acute angle, and the ischial 
tuberosities are approximated. The transverse diameters 
throughout the pelvis are greatly diminished, and the pelvic 
canal is increased in depth. 

The cause of this deformity has not been satisfactorily ex- 
plained. 



OSSEOUS TUMOES. 



419 



Spondylolisthetic Pelvis. — This is a rare form of pelvic de- 
formity, and consists chiefly in separation of the last lumbar 
vertebra from the sacral base, and descent of the lumbar spine 
Fig. 193. Fig. 194. 




Bobert's Pelvis. Spondylolisthetic Pelvis. 

into the pelvis, as shown in the accompanying cut. The result 
is a great reduction of the conjugate diameter. 

Osteo-Sarcoma and Exostosis.— These growths are of com- 
paratively frequent occurrence. They may originate from any 
part of the osseous tissue of the pelvis, but they seem to prefer 
the upper third of the sacrum. The proportions which such a 
growth may attain are well shown in the accompanying figure. 
Ftg. 195. Pelves which present these growths 

are most frequently of the oblique- 
ovate, or of the rachitic variety. 



Other Osseous Tumors and 
Projections. — Pelvic deformity 
may result from fractures of the 
pelvic bones, either by permanent 
displacement, or by the formation 
of extensive or numerous deposits 
of callus. 

Cancerous disease of the pelvic 
bones, producing tumors of some 
size and consistency, may offer se- 
rious obstructions to labor. Their 
development is not confined to any 
particular part of the pelvic structure. 




Pelvic Exostosis. 



420 LABOR OBSTRUCTED BY PELVIC DEFORMITY. 

Osseous spiculse sometimes exist, especially at the margins of 
the various pelvic articulations. The ilio-pectineal eminence, 
and the pubic crest and spine, maybe prolonged and sharp. All 
of these conditions are apt, not only to impede labor, but to 
create uterine laceration. 

Absence of the Symphysis.— This rare form of pelvic de- 
formity, termed " split pelvis " by Litzmann, consists in con- 
genital absence of the symphysis, its place being filled by strong 
fibrous bands extending between the opposed surfaces of the 
pubic bones, or by the muscles and connective tissue of the per- 
ineum. 

The Chief Causes of Pelvic Deformity.— The diseases which 
constitute the main predisposing causes of pelvic deformity are 
Rachitis, or Rickets, and Malacosteon or Osteomalacia. 

Rachitis, as we have said, is a disease of infancy, developed 
most frequently during the latter half of the first year of life. 
It very rarely appears after the establishment of puberty. It 
seems usually to rest on a scrofulous base, though it may be 
developed through the supply of food deficient in certain ele- 
ments necessary to healthy growth. The essential changes ob- 
served in the osseous constituents consist in a deficiency of the 
earthy matters, and a redundancy of the animal. But other 
changes are also wrought, resulting in the formation of certain 
new and semi-solid products. The deformities which ensue are 
not confined to any particular portion of the body, but every 
part is liable to suffer. A fact to be remembered, as bearing on 
the subject of pelvic deformity, is that rachitis is generally 
attended by an arrest of growth. The disease usually ends in 
recovery, but the deformities which have been produced, though 
sometimes slightly modified by time, forever remain. 

Malacosteon is in this country a rare disease.* While it agrees 
with Rachitis in the particular of bone-softening, it differs in 
the fact that it is a disease of adult, rather than infantile life. 

* " The deformities of the pelvis which we have to contend with in this 
country are almost entirely due to rickets ; some few are believed to be congen- 
ital, or may result from coxalgic distortion ; but cases of malacosteon. so com- 
mon in some European localities, are exceedingly rare, so much so that many 
of our most experienced obstetricians have never seen an example of this dis- 
ease." Dr. Eobt. P. Harris. Am. Jour. Obs., vol. iv, p. 409. 



DIAGNOSIS OF PELVIC DEFORMITY. 421 

It is usually developed in the puerperal state, each succeeding 
pregnancy being in some cases attended by a progressive devel- 
opment of the disease. The effects of the disease may be ob- 
served throughout the body, or they may be confined to individual 
bones. The pelvis and vertebrae are occasionally the only parts 
which suffer, especially when the disease develops in the puer- 
peral state. According to Schroeder,* the disease is regarded as 
an osteomyelitis, which, beginning in the centre of bones, ad- 
vances toward the periphery, the essential pathological processes, 
consisting in the absorption of calcareous matter, through the 
Haversian canals, and the substitution of hypertrophic me- 
dullary tissue for the softened osseous structures. The result is 
that the bones become pliable and elastic, like rubber, and, 
eventually, even of wax-like softness. 

But there are other causes of pelvic deformity, among which 
may be mentioned pelvic fracture with permanent displacement 
of all the bones; also the late establishment of puberty. Until 
the age of fourteen or fifteen years, the pelvis of the female 
differs m shape but slightly, if at all, from that of the male ; but 
as soon as the girl has her first menstrual flow, the pelvis begins 
to expand. If the appearance of menstruation is retarded to 
the age of seventeen, eighteen or twenty, the bones of the pelvis 
have become firmer, and the articulations are anchylosed without 
proper development having taken place, and without the pelvis 
having taken on the feminine characteristics. 

Diagnosis. — A positive diagnosis of pelvic deformity can be 
based only on a direct examination; but valuable data which 
point to such a condition may be gleaned from inspection, and 
the previous history of the woman. When the infantile experi- 
ences were such as usually accompany rachitis, and especially if 
there are patent physical deformities which may be referred to 
such causes, the case should be regarded with suspicion. 

The history of previous labors may throw some light on the 
subject, and, if there were connected with these, great difficul- 
ties, and much suffering, we should suspect pelvic contraction as 
lying at the bottom of it, and institute most thorough exploration. 

The special appearances of the woman, unassociated with her 

*"Lehrbuch,» p. 615. 



422 LABOR OBSTRUCTED BY PELYIC DEFORMITY. 

history, may lend a strong probability to pelvic deformity. These 
are, briefly, a square head, pigeon-breast, small stature, spinal cur- 
vature, enlarged joints, and incurvation of the long bones of the 
extremities. 

Exact measurements can be made only by means of instru- 
ments constructed for the purpose, termed pelvimeters. Numer- 
ous patterns have been devised, some of which are intended for 
external, and others for internal measurements, while some are 
designed for either mode of use. The internal dimensions are 
those sought, no matter whether it be ascertained directly by 
measuring the cavity, or indirectly, and less accurately, by taking 
the external size of the pelvis, and making alloAvance for the 
thickness of its walls. 

In nearly all forms of pelvic distortion, the conjugate diameter 
is the one which is most contracted, and hence, the instruments 
which have been devised, and the efforts which are generally 
made, have for their more especial object the determination of 
that measurement. 

For external use, Baudelocque's calipers, is probably the in- 
strument in most common use, though Schultze's is much em- 
ployed. For internal use Coutonly's, Earle's and Greenhalgh's 
are among the most prominent. 

While it is only by means of such instruments that accurate 
measurements can be taken, practical ends may be well served by 
what has been termed manual pelvimetry. For the purpose of 
ascertaining the conjugate diameter of the brim, one or more 
fingers are introduced, and the point of the index finger made 
to touch the sacral promontory, and the part of the hand upon 
which the pubic arch rests, is marked by the thumb of the same 
hand or by the finger of the opposite one. The fingers are then 
withdrawn, and the depth of introduction measured. A sub- 
traction from this of half an inch is supposed to give the real 
conjugate diameter. Such measurement will be more accurate 
if Gresnhalgh's pelvimeter is used in the manner represented in 
the accompanying cut. 

Another mode of manual measurement of the conjugate is 
shown in figure 197, but it cannot be made so exact. 

The transverse and oblique diameters of the brim, may be ap- 



INFLUENCE ON PREGNANCY. 



423 



proximately determined by introducing the four fingers of one 
hand and spreading them. 

No special directions are required to determine the diameters 
of the outlet of the pelvis, as they are so immediately under 
survey. 

FiG. 196. 




Greenhalgh's pelvimeter. 

Influence of Pelvic Contraction on the Uterus During 
Pregnancy. — In the early months of pregnancy the contracted 
pelvis favors dislocation of the uterus backwards. It is held 
down by the unusual projection of the sacral promontory, and a 
version is ultimately transformed into a flexion. 



424 



LABOK OBSTRUCTED BY PELYIC DEFORMITY. 



In the latter months, the pelvic contraction, preventing descent 
of the lower uterine segment covering the presenting part, 
maintains the organ in an unusually high situation, as a result 
of which, pendulous abdomen is sometimes observed. 



Fig. 197. 




Manual Pelvimeter^. 

Influence of Pelvic Contraction on Foetal Presentation.— 

Faulty presentations are relatively frequent in contracted pelves. 
The high situation of the uterus, and its mobility, are the chief 
factors in producing them. 

Influence of Pelvic Contraction on Labor-pains.— When 

insurmountable obstacles are encountered by the natural forces, 
the uterus, from the vehemence of its contractions, is extremely 
liable to rupture. There is also unusual danger of the organ 
tearing itself from the vagina, by its excessive retraction. After 



EFFECT ON THE CHILD'S HEAP. 425 

a time muscular action becomes weak, and lingering labor may 
result from utter exhaustion. 

Influence of Pelvic Contraction on the First Stage of 
Labor. — At the beginning of labor the head is high, and the 
lower uterine segment protrudes empty through the brim. The 
liquor amnii is driven downward with force, and still the os di- 
lates gradually. The membranes are quite apt to break prema- 
turely, when the os and cervix, which had been somewhat dilat- 
ed by the bag of waters, seem again to retract. If the contrac- 
tion is too great to allow the head to descend, the pains continue, 
and no help is afforded, uterine laceration of some form, 
after a time, is almost certain to ensue. 

Effect of Pressure on the Soft Pelvic Tissues, When Con- 
traction Exists. — The foetal head is the only part which is 
capable of producing injurious pressure, unless the arrest should 
extend over a long period. In contracted pelves the most severe 
injuries are received at the brim. When the promontory is un- 
usually prominent, and when there are spiculse, or other irregu- 
lar points of pressure, the uterine tissues, which in the first 
stage lie between the head and the brim, are often crushed and 
thinned, and, at times, even perforated and torn. 

Effect of the Pressure on the Child's Head.— The tumor 
formed on the foetal cranium (caput succedaneum) is often large 
and bloody, and varies in location and form with the position 
and character of the contraction. The head also presents local- 
ized pressure marks, derived, in most cases, from the jutting 
promontory. They may be mere reddish lines, which soon dis- 
appear, or they may be so severe as to result in complete 
destruction of the tissues down to the periosteum. They are 
generally situated on the parietal bones. 

Prognosis. — The prognosis will, of course, depend upon the 
degree of deformity present. If the diameters are but slightly 
diminished, labor may be tedious and laborious, but neither the 
maternal nor foetal risk is greatly increased; but if the deformity 
is considerable, the prognosis must be relatively grave. The 
maternal mortality in these cases is at least twice as great as in 
normal pelves. The foetal mortality is excessive. 



426 LABOR OBSTRUCTED BY PELVIC DEFORMITY. 

Treatment. — Even when there is but moderate contraction of 
any of the pelvic diameters, labor is likely to be more tedious 
and painful than in connection with normal pelves. 

The details of delivery in cases of pelvic deformity will be 
more fully discussed when we come to consider the various 
operations that may be required. When the fact of pelvic 
deformity so great as to require the more formidable and 
destructive operations to effect delivery, is known to the physi- 
cian early in gestation, there are certain questions which will 
arise, and which should be satisfactorily settled, with regard to 
the induction of abortion, or of premature labor. 

Induction of Abortion in Extreme Deformity. — When 
the contraction is so excessive that a viable child, of average size, 
cannot be safely delivered, early abortion should be induced. 
The foetal life, in such a case, would not weigh a grain in the 
balance, since the possibility of preserving it is out of the ques- 
tion, and we are left to act in the interest of the mother only. 
Nothing can be gained from delay, and hence the dictates of 
wisdom would lead us to the artificial interruption of pregnancy, 
as soon after it becomes manifest as may be possible. There is 
no amount of deformity which can prevent the successful adop- 
tion of some of the means for its accomplishment placed at our 
disposal. 

The Induction of Premature Labor in Deformed Pelves. 

"The induction of premature labor," says Playfair,* "as a 
means of avoiding the risks of delivery at term, and of possibly 
saving the life of the child, must now be studied. The estab- 
lished rule in this country (England) is, that in all cases of pel- 
vic deformity, the existence of which has been ascertained either 
by the experience of former labors, or by accurate examination 
of the pelvis, labor should be induced previous to the full pe- 
riod, so that the smaller and more compressible head of the 
premature foetus may pass, where that of the foetus at term could 
not. The gain is a double one, partly the lessened risk to the 
mother, and partly the chance of saving the child's life. 

The practice is so thoroughly recognized as a conservative 
and judicious one, that it might be deemed unnecessary to argue 

*" System of Midwifery," Am. Ed., 1880, p. 391. 



TREATMENT. 427 

in its favor, were it not that some most eminent authorities have 
of late years tried to show that it is better and safer to the 
mother to have the labor come on at term, and that the risk 
to the child is so great in artificially induced labor as to 
lead to the conclusion that the operation should be altogether 
abandoned, except, perhaps, in the extreme distortion in which 
the Csesarean section might otherwise be necessary. Prominent 
among those who hold these views are Spiegelberg and Litzmann, 
and they have been supported, in a modified form, by Matthews 
Duncan. Spiegelberg* tries to show, by a collection of cases, 
from various sources, that the results of induced labor in con- 
tracted pelvis are much more unfavorable than when the cases 
are left to nature ; that in the latter the mortality of the mothers 
is 6.6 percent., and of the children 28.7 per cent., whereas in the 
former the maternal deaths are 15 per cent., and the infantile 
66.9 per cent. Litzmann arrives at not very dissimilar results, 
namely 6.9 per cent, of the mothers, and 20.3 per cent, of the 
children in contracted pelvis at term, and 147 per cent, of the 
mothers, and 55.8 per cent, of the children, in artificially induced 
premature labor. 

"If these statistics were reliable, inasmuch as they show a 
very decided risk to the mother, there might be great force in 
the argument that it would be better to leave the cases to run 
the chance of delivery at term. It is, however, very questiona- 
ble whether they can be taken, in themselves, as being sufficient 
to settle the question. The fallacy of determining such points 
by a mass of heterogeneous cases, collected together without a 
careful sifting of their histories, has over and over again been 
pointed out; and it would be easy enough to meet them by an 
equal catalogue of cases in which the maternal mortality is al- 
most nil. The results of the practice of many authorities are 
given in Churchill's works, where we find, for example, that out 
of 46 cases of Merriman's, not one proved fatal. The same for- 
tunate result happened in 62 cases of Ramsbotham's. His con- 
clusion is, that 'there is undoubtedly some risk incurred by the 
mother, but not more than by accidental premature labor,' and 
this conclusion, as regards the mother, is that which has long 
ago been arrived at by the majority of British obstetricians, who 

* " Arch. f. Gyn.," b. i. s. 1. 



428 LABOR OBSTRUCTED BY PELYIC DEFORMITY. 

undoubtedly have more experience of the operation than those of 
any other nation. With regard to the child, even if the German 
statistics be taken as reliable, they would hardly be accepted as 
contra indicating the operation, inasmuch as it is intended 
to save the mother from the dangers of the more serious 
labor at term, and, in many cases, to give at least a chance to 
the child, whose life would otherwise be entirely sacrificed. The 
result, moreover, must depend to a great extent on the method 
of operation adopted, for many of the plans of inducing labor 
recommended, are certainly, in themselves, not devoid of dan- 
ger, both to the mother and the child. It may, I think, be ad- 
mitted, as Duncan contends,* that the operation has been more 
often performed than is absolutely necessary, and that the 
higher degrees of pelvic contraction are much more uncommon 
than has been supposed to be the case. That is a very valid 
reason for insisting on a careful and accurate diagnosis, but not 
for rejecting an operation which has so long been an established 
and favorite resource." The ideas of American obstetricians 
do not materially differ. 

Time for Inducing Premature Labor. — The operation once 
decided upon, the period at which premature labor should be 
induced is a matter of the greatest importance. The tables 
which have been prepared to direct the physician in fixing upon 
the suitable time, while theoretically clear and precise, are of 
less value than we might expect them to be, because of the ex- 
ceeding difficulty in estimating with accuracy the actual amount 
of contraction which exists in different cases. The table pre- 
pared by Kiwisch, which appears in various text-books on ob- 
stetrics, is as valuable as any: 

Inches. Lines. 
When the Sacro-Pubic Diameter is 2, and 6 or 7, induce labor at 30th week. 



2, 


" 


8 or 9, 


" 


it 


31st 


2, 


u 


10 or 11, 


u 


it 


32d 


3, 


II 





a 


it 


33d 


3, 


U 


1 , 


u 


u 


33d 


3, 


•' 


2 or 3, 


u 


u 


34th 


3, 


" 


4 or 5, 


II 


it 


35th 


3, 


II 


5 or 6, 


(( 


ii 


36th 



* " Edin. Med. Jour.," July, 1873, p. 339. 



TBEATMENT. 429 

"When expulsive action has been evoked, the treatment should 
be like that of labor spontaneously begun. In most instances 
the natural forces will be found adequate to the emergency; 
but in others the forceps, or turning, may be called for. As 
the result of most deliberate and judicious treatment, these 
cases may, in a large percentage of cases, be carried onward to 
a conclusion favorable alike to mother and child. 

When the conjugate of the brim is below two and three- 
fourths inches, the chances of saving the child by premature la- 
bor are too slight to be considered. Barnes has proposed in some 
cases to perform version in premature labor, especially if the 
pelvis measures less than three inches. 

When is Interference Advisable ? — When labor has once set 
in, it becomes necessary, after a time, to decide upon the proper 
moment to adopt operative measures for the woman's relief. In 
the minor degrees of pelvic deformity, it is always proper to give 
nature a fair opportunity; but, if the uterine efforts are ex- 
tremely violent, we should be careful not to allow the case to 
progress to the point of exhaustion. When the head is small, 
or the cranial bones unusually pliable, it sometimes happens, 
even in unpromising cases, that the head becomes so molded 
as to pass with perfect safety to both mother and child. 

Cases Wherein Delivery of a Living Child is Possible.— 

In this category we mean to include flattened pelves with a con- 
jugate of three inches and over, and justo-minor pelves with a 
conjugate of over three and a third inches. Below these figures, 
delivery of living children is rarely, if ever, possible. Our re- 
sources are here premature labor, craniotomy, forceps, and ver- 
sion. Dohrn collected some valuable statistics regarding the 
treatment by induction of premature labor, in pelves presenting 
the above mentioned degrees of contraction, which give a 
favorable showing for the operation. 

In labor at full term the membranes should be most tenderly 
cared for, to prevent rupture prior to full dilatation of the os 
uteri. Obliquities of the uterus should be considered, and pos- 
tural and other treatment to overcome them resorted to. The 
pains should be stimulated, when weak, and subdued when too 
strong. When, after escape of the liquor amnii, and close of 
the first stage, the head still refuses to engage the pelvic brim 



430 



LABOE OBSTRUCTED BY PELVIC DEFOEMITY. 



the disproportion may be assumed to be considerable. The use 
of the forceps on a head which is too large to become engaged in 
the pelvic brim is hazardous in even the most skillful hands, and 
to be adopted with the utmost caution.* We should give the 
natural efforts a fair opportunity, and if the head finally becomes 
fixed at the brim, the forceps may be employed with every pros- 
pect of success. But if nature is unable to accomplish fixation 
within a reasonable time, of which the physician must be his 
own judge, other measures should be at once adopted. 

Before proceeding to version we should be sure that the child 
is living, because the operation is to be made in its behalf. If it 
be found dead, perforation is the suitable treatment. Version is 
indicated only when the foetal heart is pulsating with vigor, and 
the pelvis measures between two and three-quarters and three 
and a half inches in the conjugate, with progressively increasing 
dimensions toward the outlet, and with an ample transverse di- 
ameter. The advantages derivable from turning in such cases, 
have been set forth by Sir Jas. Simpson, and his views have been 
sustained by others. 

Fig. 198. Fig. 199. 



fci* 88 *^ 





Change of cephalic form, from molding, in difficult head-last cases. 

It is but the revival of an old operation, but with its lim- 
its clearly defined, and its advantages perspicuously set forth. 
Simpson shows that the head viewed in transverse section, 
is cone-shaped, its narrowest portion being at the base, rep- 
resented by the bi-temporal diameter, and its widest part 
above, represented by the bi-parietal diameter; the variation 

* Dr. H. Williams has collected 119 cases reported since 1858, where the for- 
ceps were applied to the head above the brim, and finds that nearly forty per 
cent, of the mothers, and over sixty per cent.of the children, perished. 



TBEATMENT. 



431 



in diameters being from one-half to two-thirds of an inch. 
When the vertex presents, the broader part is in advance, 
and if the pelvic diameters are shortened, much greater force 
and much longer time will be required to drive the head 
through, than in cases of pelvic presentation, in which the 
lesser diameters descend in advance. Indeed, he attempts to 
show that, in some cases, nature may utterly fail to drive the 
head through a contracted brim, and yet delivery be safely 
accomplished by version, with greater ease and less danger than 
by the forceps. 

Other advocates of the operation have evidently shown, by 
further elucidation of the subject and the clinical application of 
Fio. 200. these theories, that it is possible 

to deliver a living child by turn- 
ing, through a pelvis contracted 
beyond the point which would 
permit a living child to be ex- 
tracted by the forceps. Goodell, 
and some others, assure us that 
a living child may be delivered 
by version through a pelvis with 
a conjugate diameter of two and 
three-quarter inches. Other ob- 
stetricians of extensive experi- 
ence, as, for example, Barnes, 
set the limits of the operation at 
from three and one-fourth inches 
upwards. 

From a consideration of all the arguments advanced on both 
sides of the question, and the clinical cases reported, it appears 
to be an established fact, that delivery of a living child may be 
accomplished in some cases of pelvic contraction, wherein both 
nature and the forceps have proved inadequate to the task. 

We should not lose sight of another advantage to be derived 
from turning in suph cases, namely, that pressure on the head 
at the brim, in the supra-pubic space, may be exercised by an 
assistant, and the extraction thereby greatly facilitated. 

Goodell and others place strong emphasis on the great advan- 
tage of antero-posterior oscillatory movements given the foetal 




s 



The transverse diameters of the 
head as viewed from above. 



432 LABOR OBSTRUCTED BY PELYIC DEFORMITY. 

body while traction is being put upon the legs.* By virtue of 
it, a powerful leverage is obtained, which must afford decided aid 
in getting the head past the narrow strait. It is mainly by 
virtue of this that the extensive molding of the head repre- 
sented in figure 201 is effected. 

Ftg. 201. 




Molding of the head at the brim in difficult cases of extraction after version. 

When the natural efforts are sufficient, after due molding of 
the head to force it into the pelvic cavity, further progress may 
be obstructed, or the pains may become weak, either condition 
bringing into requisition the forceps. 

It is manifest that perforation will be required when, after ver- 
sion, we are unable to deliver the head, or when, in unchanged 
presentations, the head cannot be delivered from the brim, the 
the cavity, or the outlet, by means of the forceps. 

Cases in which a Full-term Living Child Cannot be Born- 
few/ delivery through the natural passages furnishes the best chance 
for the mother. We have at our command in this class of cases but 
two operations, namely, craniotomy, and the induction of pre- 
mature labor. The latter, of course, cannot be performed, except 
in those cases wherein the condition of the pelvis is recognized 
for some time before the close of utero-gestation, and, hence, is 
limited to only a certain proportion of the cases which we are 
called to treat. 

The question of inducing premature labor has been elsewhere 
considered, and does not require to be taken up here. Accord- 
ingly we shall discuss the treatment of such cases only, as have 
gone on to the close of normal pregnancy. " If labor comes on 

*The wonderful tensile strength of the neck is surprising. Dr. Goodell 
(Am. Jour. Ohs., vol. viii, p. 193), says that in one case he applied a traction 
force of 100 lhs. and yet delivered a living child. 



TREATMENT. 433 

at full term," says Lusk,* "before craniotomy is proceeded to, 
an attempt should be made to gauge the degree of disproportion 
between the head and the pelvic brim, for not only is it among 
the bare possibilities that a living child may be expelled through 
a pelvis measuring less than three inches, but it is to be borne 
in mind that in pelvic mensuration even the most expert may 
make errors of a quarter of an inch." * * * "Craniotomy 
should not be performed so long as the hope exists of saving the 
life of the child." An approximate estimate of the size of the 
head can be made by palpation of the hypogastrium, conjoined 
with the vaginal touch. We may learn still more by passing the 
half -hand into the vagina, which, in such cases, is a perfectly 
justifiable procedure. 

Nor should we in this connection forget that in some forms of 
pelvic contraction, one lateral half of the brim is more capacious 
than the other, in which case it may be possible to turn the occi- 
put, in head-first cases, to that side, or, failing in such attempts, 
we may, by performing version, secure a favorable adjustment 
of the part to the anomalous outline of the brim. 

In transverse presentation, version by the feet should be un- 
dertaken, whether there appears to be any possibility of saving 
the child's life or not, and if extraction cannot be accomplished, 
the after-coming head can be perforated. 

Cases Wherein Extraction Through the Natural Passages 
Appears to be Impossible.— In cases of extreme pelvic con- 
traction, the natural forces are incapable of effecting delivery, 
and art offers but little hope to either mother or child. 

When the degree of pelvic contraction is known in the early 
months of pregnancy, we are perfectly justifiable in producing 
an abortion. If left till a late period in gestation, the only 
operations open to our election, are the Caesarean section and 
laparo-elytrotomy. We should not omit to say, however, that 
in a few instances, craniotomy has been successfully performed 
in pelves with a conjugate of only one and a half inches. Dr. 
Parry collected seventy cases of craniotomy in pelves measuring 
two and a half inches, or under, but seven of them had finally 
to be terminated by Caesarean section. Out of the whole num- 
ber, forty-three survived. Notwithstanding these comparatively 

* " Science and Art of Midwifery," p. 464. 



434 LABOK OBSTRUCTED BY FCETAL ANOMALIES. 

favorable results, we believe that the operator of limited experi- 
ence and skill, will be more likely to obtain favorable results 
from gastro-hysterotomy or laparo-elytrotomy, in such cases, 
than from craniotomy. 

We should make a distinction between cases, by taking into 
account the transverse measurement, since craniotomy can be 
performed with much greater ease and safety in pelves with an 
ample transverse diameter, than in those equably contracted. 



CHAPTER XII 

Labor Rendered Difficult or Dangerous by Some 

Unusual Condition of the Foetus, 

or its Appendages. 

Plural Pregnancy. — "In general, as we all know, women 
present us with a single child only; sometimes, however, they 
favor us with two, three, four or five at a birth, and their gener- 
ous fecundity may even exceed this number. Sennert relates 
the case of a lady, who produced at once as many as nine chil- 
dren, nor does this appear to be wholly incredible; and Ambrose 
Pare tells us of another lady, a co-rival of the former, I pre- 
sume, who gave to our species no fewer than twenty children, I 
do not say at a single birth, but in two confinements." * 

Twins are produced in one case in eighty or ninety; triplets 
in one case in seven thousand, and quadruplets in one case out 
of many thousands. There are but a comparatively few instan- 
ces on record of fixe children at a single birth. The sex of 
twins is divided, i. e. one boy and one girl, in about one-third of 
all cases. Both foetuses are boys in about thirty-five per cent, 
of cases, and girls in about thirty per cent. 

Post-mortem examinations have shown that twin pregnancy 
may result from impregnation of two ova from the same, or dif- 

* Blttkt>ell, Lectures on Midwifery, p. 364. 



PLURAL PREGNANCY. 435 

ferent, Graafian follicles, or may originate from a single ovum 
with double vitellus. The ova may not only come from distinct 
follicles, but also from different ovaries. Then, too, it is quite 
probable that by super-fecundation, or even by super-f cetation, 
twin pregnancy may be produced. 

Super-fecundation and super-f cetation are defined by Scan- 
zoni: the former being where a second impregnation succeeds 
the first, after an interval of varying duration, but before the 
formation of the decidua reflexa about the first ovum; and the 
latter, where a second impregnation takes place after the first 
ovum becomes completely inclosed by that membrane. 

Arrangement of the Membranes in Plural Pregnancy. — 

When twins are developed from two ova, each foetus has its own 
chorion and amnion, but the two may have a common decidua, 
and the placentae be united by their borders. If the points of 
original implantation be widely separate, the decidua reflexa of 
each may be distinct, and the placenta as well. When the devel- 
opment is from a single ovum, the placentae may be fused into 
one mass, or there may be but a single organ with a bifurcated 
cord. The decidua and chorion are common to both, and in 
some cases the amnion as well. Twins from the same ovum are 
always of the same sex. In triplets it is common to find one 
child derived from an independent ovum, and two from a single 
one. 

Conditions Attending Intra-uterine Development. —Twins 

at birth often present appearances differing greatly both as to 
size and other evidences of development. In other cases early 
death of one embryo takes place, but the dead and the living re- 
main together till the full period of utero-gestation has been 
completed. As stated in another chapter, the dead foetus is 
sometimes expelled, and without disturbing the uterine relations 
of its mate. Very rarely, when both children are living, but 
their rate of development has been different, the one which first 
reaches maturity is expelled, and the other is retained until its 
development has become complete. Just what bearing these 
facts have upon the question of super-fcetation or super-fecun- 
dation, we will leave for others to show. 

Labor in Plural Pregnancy.— The expulsion of the first fee- 



436 



LABOR OBSTRUCTED BY FOETAL ANOMALIES. 



tus is generally attended with some unusual difficulty, the sec- 
ond child more or less obstructing the usual mechanism of par- 
turition. This is especially true when the first child presents 
by the breech, since there is not only delay in the expansion of 
the os uteri, but in descent of the trunk, while the head delivery, 
which in single breech cases is often most difficult, is here unu- 
sually so, as little aid can be afforded by the uterus. 

Fig. 202. 




Twins in utero. 

Management of the First Birth.— But few special directions 
are required for the management of the first birth. The cord 
should be tied in two places and severed between the ligatures, 
so as to avoid hemorrhage in case there prove to be vascular 
connection between the two placentae. We have then to await 
renewal of uterine action, and the descent and expulsion of the 



PLUKAL PKEGNANCY. 437 

second child should be managed much like a case of single 
birth. 

Delay After Birth of First Child.— In general, there 
is a brief interval of rest between the expulsion of the first 
child, and the renewal of uterine action for the expul- 
sion of the second. Ordinarily, this interval does not ex- 
tend beyond a period of fifteen or twenty minutes, but in 
some cases, hours, or even days intervene. In case of un- 
usual delay, the plan of treatment has not yet become uni- 
form in either theory or practice. Some regard any interfere 
ence whatever, having for its object the delivery of the second 
child, as "meddlesome midwifery," and to be discountenanced. 
Others recommend the physician, after the usual delay of fifteen 
or twenty minutes, to rupture the membranes of the second 
child, if the presentation is natural, and stimulate the uterus to 
renewed activity. Later, if necessary to expedite delivery, the 
aid of the forceps is suggested. 

In case of transverse presentation, or of face presentation 
wherein rectification is deemed advisable, the necessary; opera- 
tion, it is agreed, should be performed without unnecessary 
delay. 

If the presentation is either pelvic or vertex, the attendant 
need not go to either extreme, but give the uterus a reasonable 
time in which to recuperate its energies, in a measure, so that 
if spontaneous action does not ensue, the powers of the organ 
may be aroused by suitable stimulation. If the membranes are 
unruptured, they may be broken after an interval of say an hour, 
when the case should be left to nature in the expectation that 
delivery will soon be undertaken. Among the remedies suitable 
to the case at such a juncture of affairs, we may refer to those 
given under the head of uterine inertia. Slight stimulation of 
the womb may be attempted by careful manipulation of the cer- 
vix, and kneading of the abdomen. If, despite of these meas- 
ures, expulsive action is not set up, the forceps may be applied, 
and delivery carefully effected, under the strict precautions 
mentioned in the observations on the treatment of uterine in- 
ertia. Version is here preferred by some, inasmuch as the parts 
have been so well dilated by the passage of the first child, that 
the conditions for success are remarkably auspicious. If the 



438 



LABOE OBSTRUCTED BY FCETAL ANOMALIES. 



second child present by the breech, and there appear to be any 
necessity for urging the delivery, the usual custom may be ig- 
nored, and the feet brought down. 

Locked Twins. — Dr. Barnes and others have called attention 
to a complication of plural labor, which, while rare, should not 
be disregarded. This consists in locking of the foetuses. When 
both children present by the vertex, both heads sometimes ap- 
pear simultaneously at the brim; but they cannot be contained in 

Fig. 203. 




Head-locking, (Barnes.). 

the pelvis at the same time, unless the latter is unusually capa- 
cious, in which case a very serious complication will be formed. 
An example of this kind is given by Keimann,* in which the 
head of the first child was delivered with the forceps, and then 
that of the second, these being succeeded first by the trunk of 
the former, and then by that of the latter. When both heads 
are discovered at the brim, one should be pushed out of the way, 
and the other, if necessary, secured by applying the forceps. 

When one foetus presents by the breech, and the other by the 
head, a similar, and more common complication may arise, as 



*"Arch. of Gynaek," 1871. 



LABOR IN PLURAL PREGNANCY. 



439 



shown in figure 204 This constitutes a formidable obstruc- 
tion, and, in a pelvis of ordinary size, is absolutely insurmount- 
able. 

In such cases it is rarely possible to disengage the heads, 
though this should be the first endeavor. It may be occasion- 

Fig. 204. 




Head-locking, (Barnes), 
ally possible to draw the second foetus past the first by means 
of the forceps. Failing in such an attempt, the upper head may 
be perforated, and then delivered, or it may be decapitated and 
left in utero until after delivery of the lower head. 

Double Monsters.— When the bodies of two foetuses are par- 
tially fused together, the management of delivery becomes a 



440 



LABOR OBSTRUCTED BY FCETAL ANOMALIES. 



most responsible and difficult undertaking. Nature is generally- 
equal to the emergency, as will be seen when we observe that 
out of thirty-one collected cases, twenty were spontaneously and 
easily terminated. These results are partially explained by the 
fact that, in quite a number of such cases, labor is premature, 
while in others, the foetuses are dead and somewhat decomposed. 
The Mechanism of Delivery. — The mechanism of delivery 
will vary according to the character of the anomaly, but the chief 

Fig. 205. 




Double Monster. 

difficulty is usually in the delivery of the heads. In head last 
cases it is of prime importance to carry the bodies well forward 



DOUBLE MONSTER. 441 

over the maternal abdomen, in rational attempts at delivery of 
the heads, so that one may enter in advance of the other. 

In head first cases, expulsion is commonly effected by the bo- 

Fig. 206. 




Double Monster United Anteriorly. 

dies performing a movement somewhat like that of spontane- 
ous evolution in transverse cases. The head and body of one 
foetus passes, and then the pelvis of the second in advance of the 
head. 

When delivery of living children is impossible, the body of 

one must be mutilated to make room for the escape of the other. 

The result to the mothers does not appear to be so disastrous 



4A2 LABOR OBSTRUCTED BY FCETAL ANOMALIES. 

as might be expected. Their dangers, however, are considera- 
bly augmented. 

Intra-Uterine Hydrocephalus. — Under this title we mean to 
include all the dropsies of the head, and all the extensive effu- 
sions or infiltrations of serum within or without the cranium ; 
but inasmuch as the latter are very rarely sufficiently extensive 
to constitute an obstacle to delivery, we shall confine our obser- 
vations chiefly to the internal variety. 

Hydrocephalus interims is a disease of rare occurrence. In 
43,555 labors, Madame Lachapelle observed but fifteen cases. 

It must be regarded as a most serious complication of labor. 
Out of seventy-four cases collected by Dr. Keiller, of Edin- 
burgh, sixteen, or about twenty-one per cent, were accompanied 
by uterine rupture. Nor is this the only danger to which the 
woman is exposed. The head, when excessively developed, con- 
stitutes an insuperable obstacle to delivery, the uterus after 
a time becomes exhausted, and there supervene the dangers at- 
tendant on uterine inertia, not least among which, in neglected 
cases, is that of long-continued pressure of the soft pelvic 
tissues. 

Diagnosis. — Playfair says that "the diagnosis of intra-uterine 
hydrocephalus is by no means so easy as the description in ob- 
stetric works would lead us to believe." * * * "Asa matter 
of fact, the true nature of the case is comparatively rarely dis- 
covered before delivery; thus Chaussier found that in more than 
one-half of the cases he collected, an erroneous ^diagnosis had 
been made." 

Whenever the labor is difficult, without other apparent cause 
than the size of the foetal head, our suspicions should be 
aroused. These will be strengthened by separation of the pari- 
etal bones at the sagittal suture. A positive diagnosis cannot 
be made without introducing the hand into the vagina, and the 
fingers into the womb; hence it should be regarded as not only 
the privilege, but the duty, of the physician, in suspected cases, 
— in fact in any case where the diagnosis cannot otherwise 
be clearly established, — to thus proceed. 

"The unusual size and dimensions of the head might be thus 
ascertained," says Simpson* "but one source of fallacy is to be 

■* Selected, "Obstet. Works," p. 385. 



INTKA-UTEKINE HYDROCEPHALUS. 



443 



guarded against, namely, that the sutures and fontanelles are 
not, as was usually described, always preternaturally open and 
enlarged in hydrocephalic cases; for the cranial bones are in 
some instances, where the internal effusion is great, so largely 
and abnormally developed as to destroy this supposed pathog- 
nomonic sign, and to form an almost complete osseous covering 
for the enlarged head." 

Chaussier found, as before stated, that in more than one-half 
of the cases he collected an erroneous diagnosis had been made.* 

In seventy-four cases collected by Dr. Thomas Keith, uterine 
rupture occurred sixteen times. 

Fig. 207. 




Hydrocephalic head at the brim. 

Head-last Cases. — Other than head presentations are more 
common in connection with hydrocephalus than any other con- 
dition of the foetus. According to Scanzoni, out of 152 cases, 30 
presented by some other part than the head. In such a presen- 
tation the difficulties of the case will not be realized until the 
trunk has passed, and the head comes to engage the superior 
strait. The extraordinary cranial dimensions are recognized, 
but the precise character of the complication will not easily be 
determined. The finger cannot be made to reach far enough to 

* Gaz. Medical, 1864. 



444 LABOR OBSTRUCTED BY FCETAL ANOMALIES. 

feel the peculiar features of hydrocephalus. However, if by 
conjoint manipulation, — one hand on the abdomen and the fin- 
gers of the other in the vagina, — the remarkable size of the head 
is made out, and further, if the body of the foetus presents the 
shriveled appearance so generally observed in connection with 
intra-uterine hydrocephalus, diagnosis may be made with some 
degree of confidence. 

Fig. 208. 




Hydrocephalic head — front view. 

Treatment. — The treatment in any presentation is to tap the 
head by means of an aspirator needle or small trocar, after 
which delivery may be left to the natural efforts; it may be 
terminated with the forceps or the cephalotribe; or version may 
be performed as recommended by Schroeder. We do not recoil 
from such an operation in cases like these, as we would under 
other circumstances, inasmuch as hydrocephalic children rarely 
live. 

When the pelvic extremity presents, the head should be per- 
forated behind the ear, a thing generally, but not invariably, 
accomplished without much difficulty. Tarnier relates a case 
in which he divided the vertebral column with a bistoury, and 
introduced an elastic male catheter into the vertebral canal, 
through which he relieved the cranial distension. 

Hydrothorax. — This is a rare complication of delivery. It 
is indicated by enlargement of the thorax, widening of the inter- 
costal spaces, and fluctuation therein. If distension is great 



ASCITES. 



445 



Fig. 209. 



enough to prevent delivery, paracentesis thoracis must be per- 
formed. 

Ascites, and Vesical Distension. — Ascites is more frequent 
than hydrothorax. It gives rise to abdominal distension and 
fluctuation. Descent is accomplished, and a part of the trunk is 
expelled, when labor is arrested by the presence of a large, soft, 

fluctuating tumor, which 
proves to be the distended ab- 
domen. Tapping with an as- 
pirator needle is the form of 
treatment to be adopted. 

Vesical distension can rare- 
ly be differentiated from as- 
cites in an undelivered foetus. 
If the pelvic extremity is the 
presenting part, it may be 
found practicable to pass a 
small rubber catheter, and 
thus be enabled to distinguish 
the one condition from the 
other. Otherwise the treat- 
ment recommended for asci- 
tes would here be suitable. 

Other Abnormalities of 
the Fcetus. — Foetal tumors of 
various parts, such as spina- 
Mode of perforating the head in pelvic bifida, hydroencephalocele, or 
presentations. dydro rachitis, as well as tu- 

mors of the liver, spleen and kidneys, may obstruct labor, but 
they are rarely large enough to do so. When their contents are 
fluid they should be drawn off, if necessary; and in the case of 
solid growths, evisceration may be required. 

Other Deformities. — Other deformities of the foetus, such as 
those presented by the anencephalus, acephalus, and acrania, as 
well as defective development of the thorax or abdominal parie- 
ties, with protrusion of the viscera, are rarely capable of proving 
obstructive to labor, but their anomalous features may render 
diagnosis difficult, and often impossible. 




446 



LABOR OBSTRUCTED BY ECETAL ANOMALIES. 



Fig. 210. 



Large Foetuses. — While the average weight of the foetus at 
birth is about seven and a half pounds, it is often considerably 
exceeded. What adds to the difficulties of labor in such cases, 
is the strong tendency of large children to unusual cranial firm- 
ness and ossification. The same general principles must control 

the treatment, which are set 
forth in connection with 
pelvic contraction. If na- 
ture is unable to complete 
the delivery, on account of 
undue size of the foetal 
head, the forceps will usu- 
ally, — we may say, nearly 
always, — be adequate to the 
emergency. In rare cases 
perforation will be requir- 
ed. 

Effect of Large Trunk 
on the Progress of labor. 

— When the trunk of the 
child is unusually large, if 
delay occurs, it is nearly always in connection with the expulsion 
of the shoulders. The delay at that point may be so prolonged 

Fig. 211. 




Dr. M. M. Walker's case of acrania- 
front view. 




Dr. M. M. Walker's case of acrania — lateral view, 
to sacrifice foetal life. In a few recorded cases it has been 



DORSAL DISPLACEMENT OF AliM. 



447 



found utterly impossible to extract the trunk without eviscer- 
ation. Considerable delay is not very unusual. The head pass- 
es, and then the uterus enjoys a season of repose. Meanwhile 
foetal respiration is impossible, and the placenta, owing to uter- 
ine condensation, may be separated, and the child fail to re- 
ceive its necessary supply of oxygen. It is plain that such a 
condition cannot long prevail without destroying foetal life. 

A woman was recently confined by the author with her fourth 
child. The three former children were all still-born, and her 
medical attendant, a man of skill and experience, informed her 
that the cause of the stillness was in each case long retention of 
the trunk after expulsion of the head. In the fourth labor a 
like complication arose, and only with the greatest difficulty were 
the shoulders extracted in time to save the life of the child, after 
protracted resuscitatory efforts. 

Treatment. — Efforts at shoulder extraction, are, in such cases, 
made under most unfavorable conditions. The pelvic outlet is 
usually sO well filled that the fingers cannot reach the axillae, 
while traction on the head is a dangerous procedure. The first 
efforts should be to stimulate uterine contraction by abdominal 
friction, and slight traction on the foetal head. These are usually 
Fig. 212. sufficient. Should they fail, stronger traction 

may be made on the head, but not to exceed a 
few pounds, while forcible, but careful, abdom- 
inal pressure should be exerted by an assistant. 
By such combined endeavors, success will nearly 
always be achieved. We should not omit to say, 
however, that rotation of the bis-acromial diam- 
eter into the conjugate of the outlet, is here a 
real necessity, and it may be favored at first by 
rotary pressure of the fingers upon the shoul- 
ders, and subsequently, by suitable traction with 
the fingers in the axillae. The blunt hook may 
be of service in some cases. 

Dorsal Displacement of the Arm.— In these 
really difficult cases the arm is applied to the 
side of the head so that its bulk is added fro the 
bi-parietal diameter, while the forearm is flexed at the elbow 
and the hand lies behind the occiput. 




Dorsal displace- 
ment of the arm 



448 LABOR OBSTRUCTED BY F(ETAL ANOMALIES 

It is to be treated by hooking the fingers into the bend of the 
elbow, and pushing the arm forward until it is finally made to 
sweep over the chest. 



CHAPTEE XIII. 

Labor Rendered Difficult or Dangerous by Some 
Unusual Condition of the Foetus or its 

Appendages.— ( Continued. ) 

Unavoidable Hemorrhage, — Placenta Prsevia. — In order 
that one may obtain a just conception of what is signified by 
the term "unavoidable hemorrhage," it is essential that he have 
a lucid idea of the anatomical and physiological factors inyolved. 
An exhaustive exposition of these is not here designed, and the 
facts will be as concisely stated as clearness will allow. 

In pregnancy as it ordinarily exists, the fecundated ovum 
upon entering the uterine cavity, lodges upon one of the shelves 
formed by the tumefied and rugose mucous membrane, in the 
superior portion of the uterine cavity, and at this point, forms 
its attachments. Development here proceeds to full maturity, 
and as the os uteri expands in parturition, and the foetus de- 
scends, the placenta, because of its favorable situation, suffers 
no necessary separation until after expulsion of the child, and 
the consequent termination of its functional activity. In other 
cases, happily few in number, the formative processes pursue an 
anomalous course, ultimating in great suffering and peril. The 
little egg, heavy with possibilities, escapes the physiological 
prehensile forces of the superior portion of the uterine cavity, 
and sinks by its own weight to a lower point, where it lodges, 
and soon contracts its placental relations. As foetal supplies 
are all carried through the utero-placental circulation, a consid- 
erable basis of supply is established on the lower segment of 
the uterus. The relative proportions of the part are augmented, 



PLACENTA PK^EVIA. 



449 



from both physiological and mechanical causes, small vessels 
becoming blood channels of remarkable size. The presenting 
part, usually the vertex, rests down upon this, and, when labor 
begins, and expansion of the os uteri sets in, there is more or 
less disruption of vascular relations. The placenta, an organ of 
the utmost vascularity, occupies the lower uterine segment, and 
covers the internal os uteri, and as the maternal sinuses have been 
formed over and about the closed os, the very commencement of 
dilatation must begin the process of placental separation. Foetal 
expulsion cannot occur without dilatation of the os uteri, and the 
os uteri cannot expand without rupturing blood vessels, and giv- 
ing rise to hemorrhage, — hence the name — unavoidable hem- 
orrhage. 

FlG - 213 ' Varieties.— The placenta, as 

a rule, is not situated precisely 
over the centre of the lower seg- 
ment of the uterus, but rather, 
more or less to one side, — on the 
right, or the left, anteriorly or 
posteriorly. The nomenclature 
of placenta prsevia correspond- 
ingly varies. Thus we have 1. 
Lateral placenta; 2. Latero-cer- 
vical placenta; and 3. Cervico- 
orifical, or Central placenta. 

For practical purposes we may 
make but two classes, the first 
being termed partial, marginal 
or incomplete, and the second 
being known as total, central or 
complete placenta prsevia. 

Frequency.— Placenta previa 

Varieties of placental attachments, is a complication of pregnancy 
EE.fun&dl Pjacenta; D. D. lateral an( j parturition which is en- 
placenta; F. F. C. B. latere— cervical * . 
placenta; A. B. B. F. seat of cervico- countered once in about every 
orifical, or central placenta. fi ve hundred cases. 

Causes of the Hemorrhage. — The causes which are pro- 
posed to account for the excessive hemorrhage in connection 




450 LABOR OBSTRUCTED BY FCETAL ANOMALIES. 

with placenta praevia, have been matters of considerable dispute. 
The earlier, and, usually, light losses, which are in most cases 
suffered, have been regarded by some as accidental. This may 
be true in a small percentage of cases, but it can hardly be ac- 
credited concerning the phenomenon in general. The immediate 
causes of the bleeding, which unavoidably takes place in pla- 
centa praevia, were shadowed forth in the introductory observa- 
tions, but here we may give them form and shape. It is said 
that during the first five months of utero-gestation, develop- 
mental energy is exerted more especially in the superior portion 
of the womb, during which period the cervical region is but 
slightly modified. Subsequently there is a change, we are told, 
and very soon the cervical canal is encroached upon by the capit- 
ulation of the internal os, and that, for a considerable time 
before labor, the os externum is alone left for future dilatation. 
In support of this theory, progressive shortening of the cervix 
uteri is cited. Hence, they say, as soon as the cervical canal be- 
gins to expand, by reason of the submission of the os internum, 
small arterial twigs in the utero-placental vascular system are 
apt to be broken, and hemorrhage to result, but coagula soon , 
form and arrest the flow. This experience may be repeated from 
time to time. 

We have elsewhere taken occasion to express our want of con- 
currence in the theory upon which this explanation rests. We 
are convinced, from attentive observation of the phenomena in- 
volved, that cervical shortening is more apparent than real, and 
that the internal os uteri generally preserves its contraction up 
to, or near the beginning, of labor. Hemorrhage in these cases 
may be due to the increased strain put upon the lower uterine 
segment after the sixth month of pregnancy, the uterine walls 
yielding to the force more rapidly than the utero-placental ves- 
sels, and thus giving rise to rupture of some of their twigs, or 
lesser vessels. It may be, too, that, in placenta praevia, the 
anomalous development going on about it, may make the inter- 
nal os more patulous than in normal cases. 

But there comes a time when, through the rhythmical uterine 
contractions, the cervical canal becomes at first funnel-shaped, 
and afterward wholly expanded, and the external os is left as 
the tardy part. As this movement begins, blood gushes forth 






PLACENTA PREVIA. 451 

from ruptured vessels, but whether the hemorrhage is from the 
uterine or the placental side, is still a question. It may be from 
both. The weight of opinion appears to be that the blood is- 
sues mainly from the uterine surface, though it cannot be de- 
nied that strong evidence can be adduced in favor of the oppo- 
site view. 

Symptoms. — The patient, perhaps, is lying asleep in bed, or 
she may be occupied in the performance of her household du- 
ties, when suddenly the blood bursts from the uterus, followed, 
perchance, by fainting, and sometimes, though rarely, by death 
itself. 

In some women an occasional flow occurs for a number of 
weeks before the onset of labor. It comes for a moment pro- 
fusely, and then it disappears, so that aid is not often secured in 
time to be of particular service. The final hemorrhage sets in 
similarly, and continues with uneven progress until arrested by 
well directed treatment, or brought to a close by utter exhaus- 
tion. In other cases, there is no warning whatever. Gestation 
proceeds in an uneventful course, and, full of animation and 
hope, the woman is contemplating the near approach of the time 
when the restraints of pregnancy shall be removed, and the 
trials and pains incident to its termination be succeeded by the 
tender delights of maternity, when suddenly she is precipitated 
into despair, and perhaps death. There is a gush of fluid, which, 
on inspection, is found to be blood, and it pours forth in a sick- 
ening stream. If it continues, the respiration becomes sighing, 
the pulse rapid, feeble, and finally absent, the countenance 
gets pallid, the extremities grow uneasy, syncope follows, and 
even death. The torrent may spontaneously cease for a time, 
ere these extreme symptoms are developed, and the worst will 
seem to have passed, when a renewal of the flow ensues, and 
death claims his victim. 

For a time the uterus may act with its wonted energy, but ex- 
cessive depletion is apt soon to paralyze its efforts. Occasion- 
ally labor hastens on its course, and if favored by a passive and 
sparing flow, soon reaches a stage in which an incubus is laid on 
the bleeding surfaces, and the pernicious bleeding is brought to 
a close. In other cases, after the loss of a great quantity of 
blood, the flow spontaneously ceases, and does not return, and 



452 LABOR OBSTRUCTED BY FCETAL ANOMALIES. 

labor thenceforth takes a normal course, unless complicated by- 
great weakness. 

These are exceptional cases, for when the tide of vital fluid is 
not held in check by artificial means, or the conditions on which 
it depends are not rectified by judicious treatment, the fountains 
of life soon run dry. 

In rare cases the placenta, through energetic uterine action, 
is separated and driven down into the vagina, in advance of the 
foetus. When this takes place before depletion has become too 
excessive, the outcome is usually favorable. 

When the case is of the incomplete variety, there is some- 
times but a moderate flow at any time, and even that is soon 
subdued by either natural or artificial means, and serious dan- 
ger thereby averted. This result is explained by the slight ex- 
tent of necessary separation, and the early descent of the pre- 
senting part into the pelvic inlet 

Diagnosis. — However small a figure may be cut by diagnosis 
in certain diseased states and obstetric conditions, it is here of 
surpassing importance. The perils of the emergency, and the 
possibilities of treatment are too great, to tolerate anything less 
than most careful and thorough search for the conditions upon 
which hemorrhage before delivery depends. 

The differentiation between accidental and unavoidable hem- 
orrhage will be considered when we come to discuss the for- 
mer complication of pregnancy,* but we may also here glance 
at some of the more valuable diagnostic points. 

As soon as the hemorrhage is gotten under control, we should 
investigate the history of the case, and learn under what circum- 
stances the flow began, the possible influence of accident in 
developing it, and the position of the body at the moment when 
it began. But it is only by making a thorough vaginal exami- 
nation that a positive conclusion can be reached. The os will 
generally admit the finger, not because dilated, but because of 
its dilatable condition, brought about mainly by the blood loss. 
If the finger can be passed, we shall almost always be able to 
feel some portion of the placenta. If the implantation is cen- 

* We are well aware that it is said tliat endo-cervicitis, with its slight, 
bloody discharges, may be confounded with placenta praevia, but we can 
scarcely credit the statement. 



i 



PLACENTA PRiEVIA. 



453 



tral, we shall find the cervical canal covered by a thick, boggy 
mass, which is readily distinguishable from any part of the 
foetus, and from a coagulum. By pressing upon this mass, we 
may feel the resistance offered by the presenting part of the 
foetus. When but a part of the placenta lies over the os, it will 
be distinctly felt, and through the membranes attached to it, the 
foetus will be distinctly made out. On account of a high situa- 

Fig. 214. 




Central Placenta. 
tion of the cervix, we may not be able to make a satisfactory ex- 
amination without introducing the hand. There is also a sen- 
sation of thickness and vascularity about the lower uterine seg- 
ment not observed in normal pregnancy. Furthermore, the re- 
lation, in point of time, between the crimson gush and uterine 
contraction, should be attentively observed, since their simulta- 



4:54 LABOR OBSTRUCTED BY FOETAL ANOMALIES. 

neons occurrence characterizes unavoidable, and not accidental, 
hemorrhage. 

Prognosis. — According to the calculation of Sir James Simp- 
son, based on an analysis of 399 cases, one-third of the mothers, 
and over one-half of the children, were lost. But this estimate 
does not fairly represent the results of modern treatment. Out 
of 64 cases recorded by Barnes, the maternal deaths were 6, or 
1 in 10J. Read estimates the maternal mortality at 1 in 4J 
cases. The peril is far from being equally great in all cases. 
"The question of safety in labors with unavoidable hemorrhage," 
says Meigs,* "is very much a question of time, — for if a woman 
with central implantation of the afterbirth could, as some have 
done, expel the child in one or two hours, she would not have 
time to die, inasmuch as the involution power of the womb 
would shrink the bleeding surface so speedily after the expul- 
sion as to put an end to the flooding at once, and so to all dan- 
gers and alarm. On the other hand, where the woman contin- 
ues in labor for four and twenty hours, she will probably die, 
either before or soon after its conclusion." 

The cause of the heavy foetal mortality is obvious when we 
reflect on the sources of supply, and the entire or partial placen- 
tal separation which occurs in connection with such cases. 

Treatment. — Upon clearly establishing our diagnosis, we 
should carefully consider the possibilities and probabilities of 
the case, and lay out a plan of treatment. 

On reaching our patient, we should observe the general rules 
of treatment for uterine hemorrhage, that is to say, we should 
endeavor to allay fear, we should clear the chamber of all un- 
necessary company, and we should strictly enforce the horizon- 
tal position, and the avoidance of any muscular effort. If the 
advisable course of treatment is not at the moment clear, we may 
if necessary, at once introduce a tampon to arrest the flow. 
Pressure upon the fundus uteri, which pushes the head firmly 
against the bleeding placenta, is sometimes of service. The 
question of treatment will depend somewhat on the period of 
pregnancy at which the bleeding occurs. If before the full 
term of gestation has been accomplished, the question of favor- 
ing foetal expulsion has to be decided. 

* Meigs' Obstetrics, 4th edition, p. 418. . 



PLACENTA PK^VIA. 455 

Tne Question of Favoring Foetal Expulsion.— In 1866 Dr. 
Greenhalgh, of London, recommended the induction of prema- 
ture labor in placenta previa, and though differing in their 
modes of procedure, obstetricians have come to accept it as a 
form of treatment highly practical. Erect, as we may, the 
strongest safe-guards, and yet the woman in whom the placenta 
presents is constantly exposed to great peril. At any moment, 
in waking or in sleeping hours, the torrent may gush forth, and 
the vital forces be speedily reduced to their lowest ebb. With 
the best facilities for summoning aid, life is continually in jeop- 
ardy. But, by the induction of premature labor, the entire pro- 
cess of parturition is brought under the physician's personal 
supervision, and the danger arising from hemorrhage accordingly 
reduced to a minimum. 

Over against these considerations must be set others of no 
little weight. We allude first to the almost certain destruction 
of the child which the operation involves. We should not ig- 
nore the fcetal claims; but a fair and consistent view of their 
relative importance must subordinate them to the maternal 
interests. In America it seems to have become a rule, and a just 
one, too, v/e believe, to make the mother's safety in every point 
paramount to all other considerations. Nor should we in this 
connection forget that while the induction of premature labor 
is extremely hazardous to the foetus, the chances of its living 
under the expectant form of treatment is no greater than of its 
dying. The comparatively favorable results of the former 
treatment are shown by Dr. King. Out of twenty -nine cases re- 
ported by him, there were twenty-three maternal recoveries, and 
eleven children were saved. 

"I think, therefore," says Playfair,* "that it may be safely 
laid down as an axiom, that no attempt should be made to pre- 
vent the termination of pregnancy, but that our treatment should 
rather contemplate its conclusion as soon as possible." We 
may make the single exception of diagnosis established before 
the close of the seventh month, in which case we would be jus- 
tified in temporizing until a little later period, on behalf of 
the child. 

Modes of Promoting Labor. — We have not here the same 

* Playfair, loc. cit.p. 401. 



456 LABOR OBSTRUCTED BY FCETAL ANOMALIES. 

variety of means from which to choose that is offered under 
other circumstances, inasmuch as it is essential that while we 
provide for the stimulation of uterine contractions, and dilata- 
tion of the os uteri, we furnish an obstacle to the bleeding 
which is sure to set in. Instead, then, of Kiwisch's douche, and 
other slow processes, which afford no protection from hemor- 
rhage, we are obliged to resort to other means. If the os uteri 
is very small, and the cervix is still hard in its upper portion, 
we will begin by carefully introducing a tent, tamponing the 
vagina to hold it in place. As soon as this has accomplished 
its office, it should be withdrawn and superseded by one of 
Barnes' bags. The bag is introduced in a flaccid state, and 
afterwards dilated with either air or water, and left until it can 
be followed by another of larger size. If we are merely promot- 
ing labor already begun, we would be able to begin with the 
bags instead of the tent. Hydrostatic expansive force, thus ap- 
plied, nicely simulates labor, and can hardly be regarded as im- 
posing serious danger. By filling the os uteri, and following its 
expansion, hemorrhage is kept within bounds, and labor is rap- 
idly promoted. 

As soon as dilatation has advanced to a certain extent, artifi- 
cial extraction becomes possible. The precise degree of expan- 
sion required, will depend on the state of the os with respect to 
dilatability, and the mode of delivery proposed to be employed. 
The forceps can be used through an os uteri no larger than a 
silver dollar, and if the foetal head can be gotten at, they are the 
preferable means. In other cases, and this is the most common 
treatment, turning may be practiced. 

But the foregoing treatment is not always available, nor in- 
deed successful, and other measures must be at our command. 

Evacuation of the Liquor Anmii. — This expedient is by 
some regarded as almost uniformly efficacious. Et is unsuitable 
if there is a probability of our being obliged finally to resort 
to podalic version. The favorable effect of rupture of the 
membranes arises from increased uterine condensation, and 
augmented pressure of the presenting part against the placenta 
and the ruptured uterine vessels. To these should be added the 
stimulus which is imparted to the uterus, and the consequent 
acceleration of the parturient process. 



PLACENTA PE^VIA. 457 

This operation is best performed by means of a stiff catheter, 
which, if necessary, may be passed directly through the pla- 
centa. Care should be taken not to wound the foetal head. The 
evacuation should be pretty thorough, but not very rapid. Tem- 
porary cessation of the stream, from the occurrence of uterine 
contraction, should not be taken for full evacuation. 

The Taginal Tampon.— As soon as the os uteri is thoroughly 
dilatable, whether extensively dilated or not, delivery should be 
undertaken. But in some cases this suitable moment for inter- 
ference is greatly delayed, meanwhile the tampon seems to be 
required to control the hemorrhage. It ought never to be al- 
lowed to remain unrenewed longer than eight or ten hours, for 
fear of septic poisoning from the rapid decomposition which is 
liable to ensue. To firmly pack the vagina, and maintain the 
condition unchanged for many hours, is unwise; and it is like- 
wise indiscreet to use the tampon and neglect to watch for the 
occurrence of unfavorable symptoms. It is the abuse of this 
expedient which has aroused the opposition to it which some 
declare. 

The indications for the tampon should not be forgotten, 
namely: delay of the time when extraction — manual or instru- 
mental — can be practiced, with meanwhile a profuse flow of 
blood. 

The material best suited to the purpose has not been agreed 
upon, but charpie, strips of silk, old linen and muslin, raw cot- 
ton, sponges and various other articles have been used. When 
practicable, we should not forget to employ caoutchouc bags 
in the os uteri, as they not only act as good tampons, but greatly 
aid dilatation, as well. An ordinary roller bandage is a most 
convenient and effective article. It is both introduced and re- 
moved with comparative ease. 

To thoroughly pack the vagina, the novice will find no easy 
task. It may appear to be a simple operation, and would be if 
the ostium vaginae were only wide open. But when the material 
used, whether it be muslin, silk, or charpie, is attempted to be 
introduced, one piece of ter another, the difficulties of the case 
will become apparent. The vulva must be dilated, by means of 
the fingers or a speculum. Sims' speculum answers best; but, 
if not at hand, let the fingers be used as perineal retractors, and 



458 LABOR OBSTRUCTED BY FOETAL ANOMALIES. 

the tampon can then be readily introduced. Unless well applied, 
it is worse than useless. 

The following most effectual mode of applying the tampon 
Was first recommended and practiced by Dr. Sims. " The pa- 
tient," says Dr. Paul F. Munde, in his Minor Surgical Gyne- 
cology, " (with empty rectum and bladder,) occupies the left lat- 
eral prone position; Sims' speculum is introduced and the cervix 
exposed. All coagula and fluid blood having been carefully 
removed by the dressing forceps and damp cotton, a disk-shaped 
tampon about two inches in diameter and one-half inch thick, is 
placed over the cervix. Another such tampon is rolled up and 
placed behind, another in front, and one on each side of cervix, 
and a large flat one over all these. These tampons are recom- 
mended by Emmet to be soaked in a saturated solution of alum 
and squeezed nearly dry. I always carbolize the tampons in a 
one per cent, solution, but think the alum solution a very good 
plan, as it contracts the vaginal pouch and thereby compresses 
the cervix. Occasionally it may be necessary to push a pledget 
of alum cotton into the cervical canal and thus arrest the hem- 
orrhage until the whole tampon has been firmly placed. * * * 
The first circle and layer of tampons having been arranged, as 
described, and the vaginal vault thus filled and the cervix com- 
pressed in all directions, disk after disk of dampened carbolized 
cotton is laid around the circle of the vagina, filling up the 
centre at the last, and each disk and each layer is gently but 
firmly pressed down and packed tight with the dressing forceps 
or a whalebone stick. This pressure should always be made 
from the periphery toward the centre, or rather from the ante- 
rior vaginal wall toward the sacrum. As the cotton is thus 
welded and pushed up, the room thus made is filled by new 
pledgets, until the vagina is distended to its utmost and the tam- 
pon has reached not only the floor of the pelvis, but is parallel 
with the pubic arch. After a final thorough survey of the tampon, 
and packing down any loose parts, the dressing forceps hold 
back the cotton firmly with wide- spread blades, and the specu- 
lum is carefully removed with points backward. Considerable 
care is required not to dislodge the tampon in the manoeuvre, and 
it is necessary after removal of the speculum to fill the space 
thus made by a fresh packing tight of the whole tampon, and 
perhaps by several additional disks." 



PLACENTA PE^VIA. 459 

Separation of the Placenta.— This is a mode of treatment 
which has met with some success and favor. 

Complete Separation.— Entire separation of the placenta as 
a mode of treatment in certain cases was first recommended by 
Simpson. He advised it more especially, — 

1. When the child is dead. 

2. When the child is not viable. 

3. When the hemorrhage is great, and the os uteri is nor yet 
sufficiently dilated to admit of safe turning. 

4. When the pelvic passages are too small for safe and easy 
turning. 

5. When the mother is too exhausted to bear turning. 

6. When the evacuation of the liquor amnii fails to arrest the 
hemorrhage. 

7. When the uterus is too firmly contracted to allow of turn- 
ing.* 

This practice was based on the theory that the source of the 
hemorrhage in placenta prsevia is chiefly the separated uterine 
surface of the placenta; but without accepting the theory, in 
certain cases we may find the operation a wise one. Complete 
separation of the placenta, however, is not easily effected, since 
the finger is not long enough to accomplish it. It may be done 
when necessary by introducing the half hand. 

Partial Separation. — Barnes divides the uterine cavity into 
three zones, or regions. When the placenta occupies the upper 
zone, there will be no unavoidable hemorrhage. The same is 
also true of the middle zone. But when the placenta is partially, 
or entirely, in the lower, or cervical zone, expansion of the os 
uteri to its full dimensions, involves more or less separation and 
consequent loss of blood. If but partially within the lower zone, 
the placenta may not be entirely separated, but, after expan- 
sion of the os has been accomplished, contraction of the uterine 
tissues may take place and seal the exposed vessels, and no fur- 
ther hemorrhage be excited by the remainder of the placenta 
which lies above the region of unsafe attachment. Dr. Mat- 
thews Duncan f estimates the limit of spontaneous detachment 

* " Selected Obstet. Works." p. 68. 
f " Obstet. Trans.," vol. xv. 



460 LABOK OBSTRUCTED BY FCETAL ANOMALIES. 

to extend 2J inches on every side of the centre of the os uteri. 
On the strength of this theory Dr. Barnes has proposed a mode 
of treatment which is doubtless efficient in many cases, the 
description of which is given in his own words.* 

"The operation is this: Pass one or two fingers as far as 
they will go through the os uteri, the hand being passed into 
the vagina if necessary; feeling the placenta, insinuate the fin- 
ger between it and the uterine wall; sweep the finger round in 
a circle, so as to separate the placenta as far as the finger can 
reach; if you feel the edge of the placenta where the membranes 
begin, tear open the membranes freely, especially if these have 
not been previously ruptured; ascertain if you can what is the 
presentation of the child before withdrawing your hand. Com- 
monly some amount of retraction of the cervix takes place after 
this operation, and often the hemorrhage ceases. * * * If 
uterine action return so as to drive down the head, it is pretty 
certain there will be no more hemorrhage; you may leave nature 
to expand the cervix and to complete the delivery. The labor, 
freed from the placental complication, has become natural." In 
event of failure to arrest the flow by this means he recommends 
the use of his " uterine dilators." 

A Full Bladder. — It is especially incumbent on the physi- 
cian, in the treatment of placenta prsevia, to see that the bladder 
does not become loaded with urine. The patient's anxiety and 
fear, coupled with the pain and distress she suffers, may so di- 
vert her attention that the discomfort of a full bladder will be 
disregarded. In no case, however, should she be permitted to 
arise, or materially change her position in order to perform the 
required act of micturition. It is far better to use a catheter. 

Treatment When the Os is Either Dilated or Dilatable. — 

We come now to consider the means of effecting delivery when 
once the os uteri has attained the state of dilatability which will 
admit of artificial aid, other than that already described. The 
character of the means suitable to the case will depend largely 
on the peculiar circumstances and conditions manifested in indi- 
vidual instances. In a certain proportion of all cases, the labor, 
from the moment of uterine dilatation may be safely left to the 



" Obstetric Operations," 2d ed., p. 417. 



PLACENTA PK^VIA. 461 

natural efforts. The employment of the means for arrest or 
prevention of excessive hemorrhage before recommended, will 
often be so effectual as to obviate the pressing necessity for any 
further artificial interference. There is a point sometimes ob- 
served in these cases, beyond which to go would perhaps consti- 
tute e * meddlesome midwifery." In the main, however, we find 
it necessary, in order best to conserve the patient's interests, 
and rescue her from jeopardy at the earliest possible moment, 
to complete the delivery as rapidly as is compatible with the 
low state of the vital forces and the integrity of the tissues upon 
which the strain in rapid delivery mainly falls. 

Ergot has been recommended and successfully employed in 
those cases wherein uterine contractions are too feeble to force 
the foetus onward. We should refrain from exhibiting it if 
there still remains the possible necessity for version; if any ob- 
stacle to speedy expulsion exists, which would not be easily 
overcome by forcible contractions; or, finally, if the forceps are 
not under ready command, so as to be employed'should delivery 
still be prolonged. 

The forceps, in dexterous hands, may be used early, and the 
woman thus speedily rescued from her perilous situation. The 
conditions upon which the difficulty in using them in placenta 
prsevia mainly depends, are, the height of the presenting part, 
the partial expansion of the os, and the inaccessibility of the 
head from the unusual location of the placenta. 

It is always most difficult to apply the forceps to the head 
when it lies free about the pelvic inlet. To do so it may be found 
necessary to carry the half -hand into the vagina to give direc- 
tion to the blades. The spiral sweep of the instrument, as it 
enters, must be observed, in order to acquire a firm hold of the 
head, which part might otherwise be so displaced as to prevent 
a satisfactory application. 

It is only under exceptional circumstances that we are justi- 
fied in applying the forceps through an incompletely dilated os, 
and those attending unavoidable hemorrhage constitute an in- 
stance. They who have never passed the instrument through a 
small os, will find, on attempting to do so, that, in point of diffi- 
culty, it far exceeds the ordinary introduction. To perform the 



462 LABOK OBSTEUCTED BY FCETAL ANOMALIES. 

act with success, the details of application are required to be 
observed. ♦ 

The placenta in these complicated cases, lying centrally, or 
laterally, over the partially expanded os, is a serious obstacle to 
this form of delivery. If the implantation is central, we may 
succeed in doing what has been done, i. e. in applying the instru- 
ment directly through the placenta. To do so, an aperture 
must first be made, of sufficient size to admit the blades, and 
then we may operate much as we would through a simple undi- 
lated os uteri. In such a delivery, the placenta is likely to be- 
come loosened, and be brought away, in advance of the descend- 
ing foetus, in which case the result will practically correspond 
to separation and extraction of the placenta. 

Incomplete placenta praevia is the form to which the forceps 
are more particularly adapted, as it is usually possible to turn 
aside the placenta, and reach the foetal head over its margin. 
The fingers should be slipped within the os uteri, and the direc- 
tion in which there is least attachment carefully sought. Being 
found, the placenta should be drawn aside, the membranes rup- 
tured, and the blades passed. 

It is unwise, as a rule, to apply the forceps through a rigid os 
uteri, but the co-existence of placenta praevia sometimes consti- 
tutes an exception. The hemorrhage may be continuous, and 
still the os, from exceeding nervous irritability, is spasmodically 
closed. The ordinary measures for relief are perhaps tried in 
vain. If dilatation has reached a degree which^will admit of the 
forceps being introduced, rather than suffer longer delay we may 
carefully proceed to deliver. Traction should not be really in- 
termittent in these cases, but rather remittent, to avoid the pos- 
sibility of recurring hemorrhage from a relaxation of the press- 
ure imposed on the bleeding vessels during traction. 

Version, as a preliminary to extraction, in unavoidable hemor- 
rhage, was first suggested by Ambrose Pare, and afterwards 
strongly advocated by Guillemeau. At present it is the most 
common mode of treatment, and some writers on the subject are 
so emphatic in their endorsement of it as to teach that every 
thought of placenta praevia should have associated with it the 
idea of version. 

Version can be performed by bi-manual means, without in- 



PLACENTA PREVIA. 463 

troducing the hand into the uterine cavity, but they are not often 
suitable to these cases. Version, then, when spoken of in this 
connection, means internal podalic version. The conditions fa- 
vorable to the performance of the operation, as enumerated by 
Dr. Tyler Smith, are "a dilated or dilatable state of the os 
uteri; the retention of the liquor amnii, or a moderately relaxed 
state of the uterus; a pelvis of average capacity; the absence of 
dangerous exhaustion, or a temporary cessation of the hemor- 
rhage." "Nothing," says Leishman,* "is of greater importance 
than that the operation should be attempted as early as possi- 
ble, for there can be no doubt that the great mortality which at- 
tends these cases is due, in no small degree, to an injudicious 
expectant treatment, while the precious moments pass during 
which alone we can save the patient's life and that of her child." 
In order, then, to improve the golden moment for operation, we 
must be on the alert from the earliest manifestation of unto- 
ward symptoms. When a concurrence of the above mentioned 
favorable conditions is met, podalic version may be easily per- 
formed; but the combination does not always exist, and then the 
difficulties are both numerous and formidable. 

There are two modes of performing internal podalic version, 
differing in the precise manner of passing the hand. In one, the 
hand is pressed gently into the vagina, and then through the os 
uteri, and the placenta which lies over it. In the other, instead 
of making an aperture for the hand through the placenta, this 
organ is raised on the side of least attachment. In case of com- 
plete placenta prsevia, the hand is insinuated between the organ 
and the uterine walls, and then between the thin membranes 
and the uterus, until a point opposite the feet is reached, when 
the sac is ruptured, and the extremities at once seized. Seri- 
ous, and perhaps unanswerable, objections to passing the hand 
through the placenta, as advocated by Dr. Kigby, have been 
raised by different obstetricians, and have been clearly epito- 
mized by Dr. Dewees as follows : 

"1. In attempting this, much time is lost that is highly im- 
portant to the patient, as the flooding unabatingly, if not in- 
creasingly, goes on. 

2. "In this attempt, we are obliged to force against the mein- 

* Loc. cit, p. 386. 



464 LABOB OBSTBUCTED BY FCETAL ANOMALIES. 

branes, so as to carry or urge the whole placentary mass toward 
the fundus of the uterus, by which means the separation of it 
from the neck is increased, and, consequently, the flooding aug- 
mented. 

"3. When the hand has even penetrated the cavity of the ute- 
rus, the hole which is made by it is no greater than itself, and, con- 
sequently, much too small for the foetus to pass through with- 
out a forced enlargement; and this must be done by the child 
during its passage. 

" 4. As the hole made by the body of the child is not suffi- 
ciently large for the arms and head to pass through at the same 
time, they will consequently be arrested; and if force be applied 
to overcome the resistance, it will almost always separate the 
whole of the placenta from its connections with the uterus. 

"5. That, when this is done, it never fails to increase the dis- 
charge, besides adding the bulk of the placenta to that of the 
arms and head of the child. 

"6. When the placenta is pierced, we augment the risk of the 
child, for, in making the opening, we may destroy some of the 
large umbilical veins, and thus permit the child to die from hem- 
orrhage. 

" 7. By this method we increase the chance of an atony of the 
uterus, as the discharge of the liquor amnii is not under due 
control. 

"8. That it is sometimes impossible to penetrate the pla- 
centa, especially when its centre answers to the centre of the os 
uteri; in this instance much time is lost that may be important 
to the woman." 

Explicit rules for performing podalic version will be given in 
another place, and we shall here indicate only the general out- 
lines of the operation as performed in these cases. 

By locating the sounds of the foetal heart, we can determine with 
certainty toward which side of the mother lies the foetal back, 
and thus make choice of the hand with which the operation can 
more easily be performed. Oiling the hand on its outer surface, 
it is passed within the vagina, and then slowly between the uterus 
and placenta, and later, the uterus and membranes, until it 
reaches a point opposite the child's feet. The membranes 
should then be ruotured. the feet secured, and brought down, 



PROLAPSE OF THE FUNIS. 465 

until version lias been fully wrought. After once the hand en- 
ters the os uteri the hemorrhage is arrested by the plug which 
occupies the part, viz: first the hand, then the wrist, then the 
forearm, and, ultimately, with a reversion of this order, by the 
body of the child itself. 

Podalic version, always a formidable operation, is doubly so 
in such emergencies, owing to the excessive depression of the 
vital force by which, in most cases, it is preceded. 

When examination discloses a presentation of the pelvic ex- 
tremity of the child, whether it be breech, feet or knees, we may 
vary somewhat the practice usually advised in such cases, by 
bringing down a foot. As the characters of the presenting part 
in placenta prsevia are obscured by the interposed placenta, they 
cannot generally be made out.until the time for interference ar- 
rives, and the hand is passed into the vagina for operative pur- 
poses. In pelvic presentation, we have, then, but to proceed 
and bring down a single foot, or both feet. 

In the treatment of unavoidable hemorrhage during delivery, 
or before, we can expect but little aid from drugs administered 
in any form. If the woman's energies are broken, and the uterus 
is inactive, by the exhibition of china, Pulsatilla, secale, cam- 
phor, or caulophyllum, some help may be given. China ought 
to be exhibited in every case of excessive blood loss. If the os 
uteri is spasmodically closed, belladonna, gelsemium, aconite, or 
caulophyllum may mollify it. But none of these remedies can 
have direct influence over the hemorrhage itself, which consti- 
tutes the alarming symptom. 

After labor, our remedies will be of great service. Arnica, if 
promptly administered, alone, for a time, or in alternation with 
china, is capable of averting serious ills. In the puerperal 
state, unfavorable symptoms are unusually prone to appear in 
these cases, and the remedy especially indicated will overcome 
them, and impart a powerful impulse toward perfect recovery. 
Prolapse of the Funis. 

This is a complication which does not in any manner retard 
the labor or make it difficult, but what gives it significance is the 
danger in which its occurrence places the foetus. A loop of the 
cord descends by the side of the presenting part, and is liable 
to severe compression between the foetus and the pelvic walls. 



m 



LABOE OBSTRUCTED BY FCETAL ANOMALIES. 



The consequence of such an accident is serious interruption 
of the foetal circulation, and destruction of the child from asphyx- 
ia. 

Frequency of Occurrence. — It is not generally regarded as 
of frequent occurrence, but it is probable that moderate prolapse 
takes place in some cases without detection, and results in foetal 
death. A loop of cord may descend far enough to suffer com- 
pression at the superior strait, without being detected in an or- 
dinary vaginal examination. It has been observed once in 300 

Fig. 215. 




Prolapse of the Umbilical Cord. 

or 400 cases. Playf air and others have called attention to its re- 
markable prevalence in certain districts, which phenomenon is 
attributed largely to the unusual number of rachitic pelves in 
such places. As between France, England and Germany, it is 
less frequent in France and most frequent in Germany, the re- 
spective figures being 1 in 446|, and 1 in 207^, and 1 in 156. Dr. 



PROLAPSE OF THE FUNIS. 467 

Simpson believes that these national differences are occasioned 
mainly by the varying positions in which women are placed dur- 
ing labor, but this interpretation of the causative influences 
which are responsible for such widely different experiences, 
seems to lack the strength of probability. 

Prognosis.— To the foetus, prolapse of the funis is one of the 
most serious possible complications of labor. In 355 cases col- 
lected by Dr. Churchill, 220 children, or nearly two-thirds, died. 
These, however, were mainly hospital cases, and it may be that 
in private practice the mortality is not quite so great.* 

It is evident that compression of the cord is the main cause of 
so heavy a death-rate; but some authors attribute it in part to 
partial loss of fluidity of the blood from being chilled as it 
passes through a loop of cord which protrudes from the vulva. 
This effect of exposure has been questioned by many, among 
them Madame Lachapelle, who says,f " I have seen the cord 
hang out of the vulva for several hours together without the 
foetus suffering therefrom in anywise, because there was no com- 
pression; and this, in some of the cases, notwithstanding the 
patients had come a greater or less distance, either on foot or in 
some vehicle, from their residences to our hospital." The wri- 
ter has likewise recently delivered a woman in whose case the 
cord had been prolapsed for two or three hours, and when felt, 
seemed cool and pulseless, and still the child, though feeble, was 
easily revived. 

Mortality is greatest in vertex presentations, and least in 
breech cases; the explanation of the varying results being the 
greater force and duration of compression in one case than in 
the other. It is also heavier in first, than in subsequent labors. 

The Causes. — Prolapse of the funis results from a variety of 
causes, among which are unusual length of the cord itself, a re- 
dundancy of liquor amnii, irregularities of the pelvic brim, 
obliquity of the long uterine axis, positions and presentations of 

*Out of 743 cases compiled from various authorities by Scanzoni, only 335 
of the children were saved. Out of 202 cases of vertex presentation with pro- 
lapse of the funis, tabulated by another, only 76 children were saved. 

t Vide Cazeaux. "Theoretical and Pract. Midwifery," Am. Ed., 1878, p. 
831. 






468 LABOR OBSTRUCTED BY ECETAL ANOMALIES. 

the foetus which do not occupy the full outline of the pelvic 
brim, and low attachment of the placenta. In the front rank of 
proximate causes we must place sudden and rapid escape of the 
liquor amnii. In most cases of labor, the presenting part 
presses well down on the brim, and rupture of the membranes 
during a pain is attended with escape of only that part of the 
amniotic fluid which is confined below. But in other cases, the 
presenting part does not rest at the brim with so firm and equa- 
ble a pressure, and when the bag of waters breaks, a large part 
of the liquor amnii escapes with a gush, and may bring down 
with it a loop of the cord. 

Signs of Funis Presentation.— The signs of prolapse of the 
umbilical cord are usually sufficiently well marked to make their 
diagnosis easy. Descent is often so great that a loop of the cord, 
three or four inches in length, protrudes from the vulva. Pul- 
sation may be present or absent. When present it is sometimes 
so feeble as almost to escape detection. If pulsation is distinctly 
felt, this alone would establish the diagnosis. If absent, the 
twisted arrangement of the vessels, always plainly felt, or visual 
examination, will remove all doubt. When only a piece of the 
loop can be felt at the brim, it might be mistaken for a finger or 
toe, unless the examination were pressed. It seems hardly cred- 
ible, but a loop of intestine, prolapsed through a rent in the 
uterus, in more than one instance has been mistaken for the um- 
bilical cord. 

When only a knuckle of the cord drops down below the brim, 
it is so small that it may escape attention, and the child be sac- 
rificed without any suspicion of danger having been excited. 

Has Pulsation Ceased? — It is of the utmost importance that, 
in prolapse of the funis, we determine whether or not the cord 
be pulsating, since if pulsation has actually been absent for say 
fifteen minutes, we are safe in assuming the child to be past 
recovery, and will resort to no interference on account of the 
complication. Mere inability to at once detect pulsation is not 
sufficient ground upon which to rest the expectant treatment. 
It is remarkable how soft and indistinct are the pulsations in 
some cases, as the author has recently had occasion to observe. 
It should be remembered in this connection that an examination 
of the cord made during a pain is liable to mislead, as compres- 



PKOLAPSE OF THE FUNIS. 469 

sion at such a time only may be sufficiently great to interrupt the 
circulation. 

Treatment. — Prolapse of the umbilical cord constitutes a real 
emergency, inasmuch as even a brief delay in affording relief 
may be fatal. The obvious indication for treatment is, first, 
prevention of prolapse, and secondly, relief of compression at 
the earliest possible moment. 

Preventive Treatment. — This has but a brief range of ap- 
plicability. Before rupture of the membranes, in the first stage 
of labor, the cord may occasionally be felt, coiled in advance of 
the presenting part, and ready to descend as soon as rupture 
occurs. In such a case the membranes should be carefully pre- 
served, and the woman placed in a posture favorable to sponta- 
neous return of the cord to a less exposed situation. We allude 
to the posture about to be described, which is likewise of the 
utmost value in attempts to reposit the cord after prolapse has 
really taken place. 

Fig. 216. 




Inclination of the uterus, in the dorsal posture, favoring descent of the cord 

into the pelvis. 

Postural Treatment. — So long as the woman occupies a po- 
sition on her side or back, the cord, from its very weight, will 
manifest a strong disposition to return after every reposition. 
This tendency may sometimes be overcome by carrying it deeply 
into the uterine cavity, but this involves the introduction of the 
hand. "We should not hesitate," says Tarnier,* "to carry the 

* Cazeaux's Midwifery, Am. Ed., 1878, p. 833. 



470 



LABOR OBSTRUCTED BY FCETAL ANOMALIES. 






hand up to the fundus of the womb for the purpose of leaving 
the prolapsed portion in that part of the organ." It occurred to 
Dr. T. Gaillard Thomas to invert the uterus, and thereby bring 
the force of gravity in the direction of the fundus, by placing the 
woman in the knee-elbow, or, better still, in the knee-chest posi- 
tion. The anterior uterine wall, is thereby made to form an 

Fig. 217. 




Postural treatment for prolapse of the cord. 

inclined plane down which the cord slips. With the woman in 
this posture it is in some cases found that the force of gravity 
alone is sufficient to restore the prolapsed cord, since the head or 
other presenting part ceases to press firmly on the brim, and 
nothing suffices to forcibly maintain the displacement. When 
the funis has thus been placed beyond the risk of compression, 
if the os uteri is large enough, the forceps may be applied, and 
the head drawn into the brim, thus preventing a possible renewal 
of the complication. If the forceps cannot well be used at this 
juncture, the head may be retained at the brim by firm hypogas- 
tric pressure, and the woman permitted to resume a less irksome 
position. The postural treatment is suitable to all cases wherein 
there is any hope of restoring the cord to the uterine cavity; but 
it will usually have, to be supplemented by manual and instru- 
mental aid. 

Artificial Reposition. — This should, in every instance, if at 
all practicable, be performed with the woman in the knee-elbow, 
the knee-chest, or the semi-prone position. McClintock and 



PEOLAPSE OF THE FUNIS. 471 

Hardy recommend the last position, with the woman on the side 
opposite the prolapsed cord. 

The methods of reposition vary greatly. Tarnier, as before 
quoted, thinks it justifiable to carry the cord with the fingers as 
high as the fundus uteri, while others regard even the hollow of 
the neck, in vertex presentation, as too elevated.* Unfortunately, 
reposition, when thoroughly performed, is often extremely diffi- 
cult to effect, and frequently disappointing in its results. 

Various instruments have been devised to aid in the manoeuvre, 
but few possess them, and fewer still can successfully use them. 
The fact is, that, in most cases, relief must be afforded without 
the least delay,, and the preparation of the ingenious means rec- 
ommended in many text books, consumes the very time which 
determines the issue of the case. Our own opinion is that in 
those cases wherein successful reposition is at all possible, the 
hand is a better instrument than any yet devised, and with it we 
may more safely press the cord into the uterine cavity, and main- 
tain it there. To effectually carry out this sort of treatment, 
then, we should bear in mind the following points: 

1. The knee-elbow, or the knee-chest, position, for the woman. 

2. The use of the hand to return the cord, carrying it well into 
the uterine cavity. 

3. The immediate application of the forceps, or supra-pubic 
pressure, to prevent a recurrence of the complication. 

Treatment When Reposition Fails.— Efforts at complete 
reposition often fail. Moreover, in a certain number of cases, 
labor has advanced too far to admit of a return of the cord to a 
situation high enough to escape compression, and this, too, in 
some instances, where there is good ground for hoping to save 
the child's life. Treatment will then in great measure be 
controlled by surrounding circumstances. Nor should we for- 
get that prolapse of the funis does not always necessitate pro- 
tracted interruption of the foetal circulation. The cord may be 
in a protected situation, and if it is not, we may be able to place 
it there. If pulsation has not long been absent, and labor is 
progressing rapidly, it may be completed in a natural manner, 
in time to preserve the foetus. Again, if compression has not 

* Playfair. " System of Midwifery," p. 330. 



472 LABOB OBSTRUCTED BY FCETAL ANOMALIES. 

been long-continued, and the pelvic structures are in a favora- 
ble condition, the forceps may be applied, and labor terminated 
without delay. 

If the head still lies at the brim, and all efforts at reposition 
of the cord have failed, we may have recourse to version. 
Engelmann found that seventy per cent, of the children deliv- 
ered in this way were saved. This is a point of great nicety, 
since the operation of podalic version augments the maternal 
dangers. Statistics have not been gathered upon which to base 
a rule of action in such cases, and the matter is thus left entirely 
to the judgment of the practitioner. If version can be effected 
by the conjoint method, the objections would be robbed of their 
force; but, unfortunately, this mode of operating, at such a 
time, is rarely practicable. " It is scarcely necessary to state," 
says Engelmann,* " what figures so plainly show, that version, 
preceded by judicious postural treatment, is the method to be 
followed which promises most for the life of the child, in prolapse 
of the cord, when complicating head presentations." 
Accidental Hemobbhage. 

This is a variety of uterine hemorrhage regarding which but 
little is found in the text books, or even elsewhere in obstetrical 
literature; yet it is of sufficiently frequent occurrence, and in- 
volves ample difficulty and danger, to merit more than passing 
notice. Its character, causes, and treatment, ought to be fa- 
miliar to the student of midwifery. 

Its Character. — What does the term "accidental hemor- 
rhage" signify? In one sense we may justly regard every 
flooding as the result of accidental causes, but the designation 
here made is specific. The elder Bigby, more than a hundred 
years ago, clearly drew the lines of accidental hemorrhage, and 
established its distinctions. The term is employed more espe- 
cially to differentiate between two varieties of hemorrhage occur- 
ring at a like period in pregnancy, and presenting similar fea- 
tures. Accordingly there are "accidental hemorrhage," and 
"unavoidable hemorrhage," both encountered in the latter 
months of utero-gestation, and prior to foetal expulsion. The 
former often proceeds from accident, and from this fact the des- 
ignation is probably derived. A profuse flow of blood occurring 

* Am. Jour. Obstet., vol. vii, p, 255. 



ACCIDENTAL HEMOEEHAGE. 473 

earlier than the seventh month does not assume the title, but is 
recognized as a symptom of threatened abortion. 

The Relation of Foetus and Placenta to the Uterus.— The 

placenta is in its usual situation, high upon the body of the 
uterus, or at its fundus, and the vascular relations of the several 
parts differ in no essential particulars from those recognized as 
normal. There are, in general, no anomalies in the arrange- 
ment of various parts, nothing perceptibly unusual in the rela- 
tions of the foetus to the placenta, or of the placenta to the 
uterus, which could possibly render the loss of blood in any 
strict sense unavoidable. 

The Causes. — The immediate cause of the hemorrhage is an 
incomplete dissolution of the utero-placental adhesions, and the 
consequent exposure of bleeding vessels. The remote causes — 
that is to say, the causes proposed to account for the placental 
separation — are often untraceable. In a certain proportion of 
instances, the mainspring of the broken relationship is plainly 
referable to accidental influences. The woman has suffered an 
unusual physical strain from a sudden motion, from lifting a 
heavy weight, or perhaps a light weight at disadvantage, from a 
long walk, or from reaching. Within a few moments, or hours, 
a flow of blood sets in, and a case of accidental hemorrhage is 
rapidly developed. A blow upon the abdomen may fall on the 
site of placental attachment, and partial separation be produced. 

During the latter part of pregnancy the utero-placental rela- 
tions are more feeble than at an earlier period, and it is surpris- 
ing that they are not oftener prematurely severed. It is quite 
probable that in some women the connection becomes so infirm, 
that any unusual motion, or even ordinary locomotion, is suffi- 
cient to sever it. In this connection, it should be added that 
this form of hemorrhage is a rare occurrence among young, ro- 
bust women. 

Varieties. — There are two varieties of accidental hemorrhage, 
namely: the open, and the concealed. In both the flow is occa- 
sioned by partial separation of the placenta, and in both, blood 
is poured out between the foetal envelopes and uterine walls. In 
one case it freely escapes through the os uteri, and in the other 
it meets an obstacle and remains pent up in the uterine cavity. 



474 LABOR OBSTRUCTED BY FOETAL ANOMALIES. 

The effect on the patient is much the same in either case, though 
concealed hemorrhage is attended with rather more danger, 
from the fact that its existence is not generally disclosed until 
extensive depletion has resulted. 

Symptoms of External Hemorrhage. — The symptoms of 
the open variety are manifest, and generally exhibit diagnostic 
characters. Whether preceded or not by an injury or strain, 
bleeding begins, and is not necessarily accompanied at first by 
any other symptoms of premature labor. If the loss of blood is 
but slight, it ought not to be dignified by the title of hemor^ 
rhage. During pregnancy, in nearly all stages, there is an occa- 
sional "show" of blood, which possesses no special significance. 
In connection with the flow there may be pressure in the sa- 
crum and abdomen, succeeded after a time by real recurrent 
pain. When profuse hemorrhage sets in during parturition, 
the uterine contractions generally become feeble, or entirely 
cease. 

Symptoms of Concealed Hemorrhage.— In the concealed 
form, blood is discharged between the membranes and uterine 
walls, or beneath the placenta, causing still greater separation. 
The exuded fluid is sometimes confined beneath the placenta, 
which remains attached only at its margins. A surprising quan- 
tity of blood is sometimes thus confined, causing considerable, 
and even dangerous, distention. Dr. W. Goodell collected 106 
cases,* and, from a study of their symptoms, deduced the follow- 
ing marked signs: 1. An alarming state of collapse evinced by 
coldness of the surface, excessive pallor, feeble pulse, yawns, 
sighs, dyspnoea, restlessness, retching, etc. 2. Generally, severe 
pain in the abdomen. 3. Marked distension of the uterus. 
4. When occurring during labor, an absence or a feebleness of 
uterine contractions. In addition to these symptoms, there may 
be dimness of vision and syncope. Observing such signs, the 
hand is placed upon the abdomen, and remarkable distension is 
found.' Pressure may force away the obstacle from the cervix, 
or separate the membranes or placenta wherein the flow is pock- 
eted, and the pent-up blood escape with a sickening gurgle. 
Madame Boivinf had little faith in the possibility of concealed 

* Am. Jour. Obs., vol. 1, p. 281. 

f'Memoire sur les Heniorrhagies Internes de L'Uterus," p. 92. 



ACCIDENTAL HEMORRHAGE. 



475 



accidental hemorrhage. "I cannot believe," she says, "that the 
uterus, filled with the product of conception, can, at any stage 
of gestation, admit so considerable a volume of blood, unless it 
has been recently emptied, nor can the quantity be sufficient to 
occasion the death of the woman." Velpeau entertained a simi- 
lar opinion. Dr. Meigs* "never met with a sample of this kind 
of bleeding." But facts are always more forcible than theories; 
and the evidence of fatal cases put upon record is a sufficient 
response. 

Differential Diagnosis. — Little difficulty is generally expe- 
rienced in differentiating between accidental and unavoidable 
hemorrhage, but in order to make the distinctions explicit be- 
yond a doubt, the following comparison has been arranged: 

ACCIDENTAL HEMORRHAGE. UNAVOIDABLE HEMORRHAGE. 



1. Often preceded by a blow, strain, 
or other injury. 

2. Most frequently sets in moder- 
ately and, for a time, gradually in- 
creases. 

3. There is no history of previous 
hemorrhages of recent occurrence. 



1. Rarely preceded by an injury. 

2. Generally comes suddenly and 
profusely, but often lasts only a short 
time. 

3. Hemorrhages, brief, but free, in 
a goodly number of instances, occur 
at intervals after the fifth or sixth 
month. 

4. The flow is more profuse during 
a contraction. 

5. The cervix and uterine walls as 
felt through the vagina, are generally 
thick and doughy. 

6. If the finger is passed through 
the cervical canal it generally comes 
in contact with some part of the pla- 
centa, which constitutes the present- 
ing part. 

Treatment. — Kest in a recumbent posture, perfect quiet, and 
freedom from excitement and irritation, must be enforced. The 
discreet use of cold may be sufficient to arrest the flow, or greatly 
modify it. The patient must be carefully guarded against disap- 
pearance of the external hemorrhage, and the occurrence of a 
concealed discharge. If the placenta has separated over only a 
small area, the treatment described may be fully adequate. But 
if a considerable surface of so great vascularity has been ex- 
posed, more radical measures will be called for. It is manifestly 



4. If uterine contractions are pres- 
ent, the flow is more marked in the 
intervals. 

5. The cervix uteri, and neighbor- 
ing uterine walls appear to be of 
normal thickness and feel. 

6. If the os uteri will admit the 
finger, the membranes may be felt, 
and through them, as a rule, the pre- 
senting foetal parts. 



* "System of Obs.," p. 441. 



476 LABOR OBSTEUCTED BY FCETAL ANOMALIES. 

desirable in accidental hemorrhage developed prior to the middle 
of the ninth month, to overcome the threatening symptoms, and, 
if possible, prevent premature labor. The first question to be 
answered here, as in threatened abortion is, — "Is expulsion inev- 
itable?" and if there is any likelihood of preventive measures 
succeeding, endeavors should be directed toward arrest of the 
symptoms by such means as will not tend to promote the expul- 
sive process. These are few and simple, and have, in the main, 
been indicated. Medicines can hardly be expected to have any 
direct control over the flow. Bleeding vessels are exposed, and, 
with the womb still distended by the product of conception, they 
cannot be constringed as they usually are under other conditions. 
The flow can be arrested, under the circumstances, by the for- 
mation of clots which will seal the vessels. Drugs cannot be 
expected to do that; but there is an indirect service which they 
can render, and that is to sooth the nervous and vascular excite- 
ment. To accomplish this, the law of similars is our best guide, 
though the use of morphia for the purpose is not to be con- 
demned. The nervous tension may be subdued by coffea, stra- 
monium, actoea, or ignatia, and the vascular excitement by aco- 
nite, veratrum viride, or perhaps belladonna. It should be 
remembered also, that among the best sedatives at such a time, 
are encouraging words, and perfect self-possession of the medical 
attendant. Should he evince alarm or excitement, his patient, 
however placid before, will be inoculated with the prejudicial 
ferment, and made less responsive to curative influences. 

Pressure on the fundus uteri will sometimes modify, or wholly 
arrest the loss. In applying it, much force must be avoided 
through fear that all hope of preventing premature labor may be 
destroyed. 

If foetal expulsion is clearly inevitable, the measures de- 
scribed being inadequate to overcome the flow, or if the loss is 
at all alarming, every effort should be directed toward empty- 
ing the uterus. In the conduct of a case up to the time when 
preventive measures cease to be indicated, care is exercised to 
preserve the membranes intact; but now as an approved, and, in 
most instances, effective mode of treatment, they are punctured 
or torn, and the liquor amnii drawn off. To do no more than 
merely rupture the membranes may be insufficient, and hence, 



ACCIDENTAL HEMORRHAGE. 477 

after providing an opening for escape of the amniotic fluid, it is 
better, between pains, to crowd the presenting part away from the 
brim to permit complete escape of the fluid. By such an operation 
the uterus is enabled to diminish its bulk, and by joint effect of 
condensation and compression is often able to end the hemor- 
rhage. "The puncture of the membranes," says Dr. Barnes, "is 
the first thing to be done in all cases of flooding sufficient to 
cause anxiety before labor. It is the most generally efficacious 
remedy, and it can always be applied." Occasionally the uterus 
is sluggish, and rupture of the membranes is not followed by 
the favorable result sought. In that case it must be aroused to 
action by kneading, by cold applications, by indicated homoeo- 
pathic remedies, or even by ergot, provided the other conditions 
are favorable. The tampon ought not to be used in such cases 
unless it be inexorably demanded, and, if used at all, concealed 
hemorrhage must be sedulously guarded against. An expedi- 
ent far preferable to tamponing, is to firmly press the present- 
ing part into the pelvic brim, by means of the hands on the ab- 
domen. 

Delivery by the forceps, or podalic version, should be effected 
at the earliest practicable moment. If necessary, gentle manual 
dilatation of the os uteri may be practiced, until the hand can 
be introduced, or the instruments applied. The forceps are to 
be preferred in case the vertex constitute the presenting part. 
When once applied and traction begun, the special emergency 
has passed, and the very presence in utero of the blades will be 
likely to awaken the uterus to renewed activity, while at the 
same time the head is being steadily drawn into and through 
the pelvic cavity. If the forceps are not at hand, or cannot be 
speedily obtained, or if the presentation is face or transverse, 
then podalic version ought at once to be performed. If the 
breech presents, we may depart from the common rule of treat- 
ment by bringing down a foot, and hastening delivery to the 
extent of drawing the trunk into the pelvic cavity. 



478 UTERINE EUPTUEE. 



CHAPTER XIY. 

Other Difficulties or Dangers Arising in the 
First and Second Stages of Labor. 

Rupture of the Uterus.— This most dangerous accident of 
labor is fortunately a comparatively rare occurrence. Burns 
calculates that it happens once in 940 labors. Ingleby, once in 
1,300 or 1,400; Churchill once in 1,331; Lehmann, once in 2,433; 
Jolly, once in 3,403; Ames, once in 4,883; and Harris, once in 
4,000. In these calculations, however, we do not, of course, in- 
clude ruptures of the intra-vaginal portion of the cervix uteri, 
which is an exceedingly common occurrence. In their immedi- 
ate effects, the latter are rarely of much moment, though their 
baneful influence on the health of women has been clearly de- 
monstrated. 

The Seat and Character of Lacerations. — Kupture of the 
uterus takes place much less frequently in its upper part, and 
the site of the placental insertion is rarely involved. The most 
common point of rupture is near the junction of the body and 
neck, either anteriorly or posteriorly. In a few cases the cervix 
has been torn away from the body of the organ in the form of a 
ring. 

The laceration does not always involve the entire thickness of 
the walls. In some cases the peritoneum escapes, and, in other 
instances, it is the only part that suffers. The extent of lacera- 
tion is likewise variable. When complete and extensive, the 
entire foetus and placenta, together with considerable blood, 
may escape into the abdominal cavity. The direction of the rup- 
ture varies greatly. 



ETIOLOGY. 479 

Etiology. — The predisposing causes are rather numerous, 
and variable; the nature of some of them not being clearly ap- 
prehended. The occurrence of one or more former labors is 
classed among them, and also advanced age. It seems clear, as 
well, that there are certain alterations in the uterine tissues 
which serve as predisposing causes of the accident. The walls 
of the organ, in some cases, have been found abnormally thin, 
in certain parts. Morbid conditions of the muscular fibres, 
such as accompany malignant and fibroid growths, the occur- 
rence of fatty degeneration, and the consequences of blows and 
contusions, are likewise included among the strongly predispos- 
ing causes. Dr. Trask,* who collected 417 cases, found the 
cause of rupture reported in sixty-seven cases, and of the etiol- 
ogy says: "We frequently find a diseased condition of the 
uterus." Referring now to the sixty-seven cases mentioned, he 
says: " Of this number there were thirteen healthy, twenty soft- 
ened, twenty-one thinned, one both thinned and softened, three 
at some points thinned, and at others thickened, eight diseased, 
one thinned and brittle." Then, too, pelvic deformity, or the 
existence of any formidable obstacle to delivery, may excite ve- 
hement action of the uterus, which in turn is capable of ulti- 
mating in the rupture of its own tissues. Pelvic deformity also 
gives rise to the accident, by compressing the uterine strictures 
between the jutting promontory, or symphysis, and the descend- 
ing foetal head. 

The proximate causes of uterine laceration are mechanical in- 
jury, and vehement uterine contraction. The organ, in a few 
recorded instances, has been ruptured by falls, and blows, re-= 
ceived in the latter part of gestation. The accident has also re- 
sulted from violence, or unskillfulness, in the performance of 
certain operations, as turning, and forceps delivery. The un- 
usual force of the uterine contractions which have been found 
to produce lacerations of the organ, in some well authenticated 
instances have been augmented by the injudicious use of ergot. 
Jolly collected thirty-three such cases. 

Threatening Symptoms. — In some examples of uterine rup- 
ture, the actual occurrence of the accident has been preceded 
by premonitory symptoms, but of an indefinite character. These 

* Vide "Am. Jour. Obs.," vol. xiv., p. 377. 



480 UTEEINE RUPTURE. 

have usually been described as acute, crampy pains in the hypo- 
gastrium; but, in most instances, no uncommon symptoms have 
been observed. 

Indications of Rupture. — The severity of the symptoms nec- 
essarily depend in great measure on the extent of the rupture. 
A number of cases have been reported, in which subsequent evi- 
dence of uterine laceration having taken place, has been found, 
though the woman during labor presented no very alarming 
symptoms. But there is usually a sudden, sharp, and excruci- 
ating pain, sometimes accompanied with a snap, audible to the 
patient, and even to the bystanders. Then there is a recession 
of the head or other presenting part, if not already engaged in 
the brim, and a sudden cessation of the recurrent contractions. 
If the laceration is extensive, the child commonly passes through 
it into the abdominal cavity, and its outline is easily distin- 
guishable through the abdominal walls. A coil of intestine 
may prolapse through the laceration and descend into the va- 
gina. The symptoms of collapse at once supervene, together 
with a sudden gush of blood from the vagina, while the sounds 
of the fcetal heart cease. 

The real character of the occurrence is in some cases masked 
by the maintenance of strength, the presence of the presenting 
part at the brim, and the continuance of fair pains. Dangerous 
symptoms may not develop until after the lapse of some hours, 
or even days. 

Prognosis. — The great majority of cases end fatally, but Dr. 
J. M. Kose * has reported a case wherein uterine rupture took 
place in four successive labors. Death may occur from shock 
or hemorrhage a few minutes after the accident, or may be post- 
poned for days, or even weeks, and ultimately result from peri- 
tonitis, septicaemia or pyaemia. A loop of intestine may be 
strangulated in the fissure, or be injured in reposition. As will 
be seen from the following pages, gastrotomy has saved many 
lives. 

Treatment. — An important part of the treatment is of a pre- 
ventive kind, but this has been sufficiently considered in con- 
nection with the treatment of the conditions which predispose 
to the accident. 

* " Chicago Med. Jour, and Exam.," Aug. 1877. 



TREATMENT. 481 

Uterine rupture is a formidable emergency, and requires 
prompt attention. If the child has passed wholly or partially 
into the peritoneal cavity, some advise that the hand at once be 
introduced, and, if the prospect of delivery through the rent 
appears to be at all encouraging, the attempt be made. The 
child is seized by the feet, and extraction effected as rapidly as 
the conditions will permit. In drawing the child through the 
uterine rupture, there is great danger of bringing with it a loop 
of intestine. This should be borne in mind, and an examination 
be subsequently made for the purpose of determining whether 
that complication has been induced. It is proper that we add 
right here, that there are very few cases on record of recovery 
after the performance of this operation. 

If the uterus has contracted firmly so as to close and abbre- 
viate the rent in the uterine walls, it may be clearly impossible 
to deliver through the natural passages. If the body of the 
child lies but partly within the abdominal cavity, we will generally 
succeed, unless the pelvis presents diameters which prevent ex- 
traction without perforating or crushing the head. In perforating 
the head, or applying the cephalotribe, the greatest care must be 
exercised, or it may escape the brim, and the anchorage to the 
body thus be removed only to permit escape of the entire foetus 
into the abdominal cavity. 

If the head continues at the superior strait, and there are no 
insurmountable obstacles to prevent, the forceps should be care- 
fully applied, and the labor completed. 

If there is no reasonable possibility of delivery per vias nat- 
urales, we are left to choose between gastrotomy and the ex- 
pectant plan of treatment, the latter of which modes, is practically 
to commit the woman to certain death. With respect to gastroto- 
my we borrow from Playf air when we say that " of late years a 
strong feeling has existed that, whenever the child has entirely, 
or in great part, escaped into the abdominal cavity, the operation 
of gastrotomy affords the mother a far better chance of recovery; 
and it has now been performed in many cases with the most en- 
couraging results. It is easy to see why the prospects of success 
are greater. The uterus being already torn and the peritoneum 
opened, the only additional danger is the incision of the abdom- 
inal parietes, which gives us the opportunity of sponging out 



482 UTERINE RUPTURE. 

the peritoneal cavity, as in ovariotomy, and of removing all the 
extravasated blood, the retention of which so seriously adds to 
the dangers of the case. Another advantage is that, if the pa- 
tient be excessively prostrate, the operation may be delayed 
until she has somewhat rallied from the effects of the shock, 
whereas delivery by the feet is generally resorted to as soon as 
the rupture is recognized, and when the patient is in the worst 
possible condition for interference of any kind." Not only this 
is true, but, judging from the results thus far obtained through 
gastrotomy, we cannot but agree with Dr. Kobt. P. Harris,* who 
says: "I am fully of the opinion that we ought to go much 
further than this, and operate in cases even where the child can 
be readily delivered per vias naturales, if there is a decided 
rupture with escape of blood and liquor amnii into the abdom- 
inal cavity, for the removal of these fluids is only second in 
importance to that of the foetus. In cervico-vaginal rupture 
this is not so important, as there is generally a natural drainage, 
but where the body or fundus has been freely rent, there is no 
security equal to that of opening the abdomen and cleaning 
it out." 

Comparative Results of Yarious Methods of Treatment.— 

The following table compiled by Jolly furnishes a strong 
proof of the comparative advantages afforded by gastrotomy: 

COMPARATIVE RESULTS OF VARIOUS METHODS OF TREATMENT 
AFTER RUPTURE OF UTERUS. 
Treatment. Number of Cases. Deaths. Recoveries. Per Cent, of Recoveries. 

Expectant plan. 144 142 2 1.45 

Extraction per vias naturales. 382 310 72 19. 

Gastrotomy. 38 12 26 68.4 

The relative success of different methods of treatment has 
been collected by Dr. Trask, and is tabulated as follows : 

(A) When the head and the whole or part of the body had 
escaped into the peritoneal cavity. 

(B) When the pelvis was contracted. 

GASTROTOMY. 

A. B. 

Saved. Lost. Saved. Lost. 

16. 4. 6. 3. 

* Vide Playfair's "System of Midwifery," Am. Ed., 1880, p. 432. 



TKEATMENT. 483 

TUKNING, PERFORATION, ETC. 
A. B. 

Sated. Lost. Saved. Lost. 

23. 50 15. 30. 

ABANDONED. 
A. B. 

Saved. Lost. Saved. Lost. 

15. 44. 0. 11. 

Dr. Harris has collected forty cases of gastrotomy after ute- 
rine rupture, performed in this country, out of which number 
there were twenty-one women and two children saved. 

The chances of success are much enhanced by the exercise of 
great care in the performance of the operation, and when that is 
done we may reasonably hope to raise the operation in point of 
success nearer that of ovariotomy. 

" We believe," says Dr. Trask, " that a neglect of this mode 
of delivery has contributed much to the exaggerated estimates of 
the mortality of this accident, which are so generally entertained. 
It is an operation requiring no little resolution and true courage 
under the trying circumstances in which the physician is placed, 
and consequently arises the need of settled principles of prac- 
tice to guide one in this extremity." * * * * "In short, as 
a general rule, from whatever cause we might be led to anticipate 
a protracted and difficult delivery by the natural passages, gas- 
trotomy will afford the best chance of recovery." 

The woman will require the most considerate treatment in the 
puerperal state, differing but little, however, from that given 
patients who have undergone fatiguing labor, or operative inter- 
ference. Judicious stimulation will greatly aid in overcoming 
the dangers arising from shock. 

Laceration of the Cervix Uteri. — This part of the uterus 
frequently suffers laceration during the passage of the foetus; 
indeed, there is no doubt that in the majority of cases there is 
here more or less solution of continuity. Traumatism is more 
liable to result when instruments are employed, than in unaided 
cases. The significance of cervical lesions of this sort belongs, 
as does the treatment, more properly to gynaecology. 

Lacerations of the Yagina. — Lacerations of the vagina occur 
quite frequently. Indeed, slight ruptures are very common 



484 LACERATION OF THE VAGINA. 

accidents, but as a rule, they give rise to no serious symptoms, 
and hence escape attention. Severe injuries of the sort usually 
come in connection with instrumental delivery. If the rupture 
is deep enough to include the entire thickness of the septum, 
anteriorly or posteriorly, the passage of urine or f ceces is likely 
to prevent repair, and thus a vesico-vaginal, or a recto-vaginal 
fistula result. 

But fistulse more frequently result from long-continued com- 
pression of the pelvic tissues by delay of the foetal head in the 
pelvic cavity. In such cases the tissues become devitalized, 
and as a consequence, a slough comes away within the first few 
days succeeding delivery, followed by the evidences of fistula. 

Treatment. — If lacerations of the vagina are known to exist, 
they should be thoroughly cleansed several times a day for 
three or four days with an antiseptic wash, to lessen the risk of 
septic poisoning. If they involve the septum anteriorly, it will 
be well to pass a rubber catheter, and allow it to remain for 
four or five days, in order to protect the lacerated surfaces 
from the irritation of the urine, in the hope that repair may 
take place. Should such fistulse persist, as they usually do, the 
woman must await relief from operative procedures, to be per- 
formed at a later period. 

Laceration of the Testibule. — This accident is not an un- 
common one, and it sometimes gives occasion to much annoy- 
ance.* As a result of it, and the swelling and soreness to which 
it gives rise, the woman is unable to urinate for a number of 
days after labor, and use of the catheter is attended with un- 
usual suffering. 

* In only nine cases out of twenty-five examined by Dr. Matthews Duncan 
was the vestibule untorn. 



VARIETIES. £gt 



CHAPTEE XY. 

Difficulties and Dangers Arising in the Third 
Stage of Labor. 

Post-partum Hemorrhage. — Floodings after delivery pre- 
sent a variety of symptoms, and hence may be divided according 
to their manifestations into several classes. Thus we have : 

1. External hemorrhage. 

2. Concealed, or internal, hemorrhage. 

3. Primary hemorrhage. 

4. Secondary hemorrhage. 

5. Hemorrhage of various degrees, viz: First degree, Second 
degree, Third degree. 

1. When the flow meets with no restraint, but passes the 
vulva, sometimes in sparing quantities, again in alarming 
gushes, it constitutes external hemorrhage. 

2. When, owing to some obstacle encountered at the cervix, 
the blood which flows from the uterine vessels is held in utero, 
we term it concealed hemorrhage. 

In the same category may also be included that form of bleed- 
ing which escapes the attention of those under whose care the 
woman has been placed, until a considerable pool has 
formed in the centre of the bed. Such flooding is, sometimes, 
but should never be, concealed from view and knowledge. 

3. When bleeding in any considerable quantity occurs within 
the first two or three hours after labor, it is regarded as primary. 

4. When postponed until a later period, it is properly second- 
ary. 

5. Hemorrhage of the first degree is that wherein but little 



486 POST-PARTUM HEMORRHAGE. 

blood is lost, though for a moment it may flow in a stream. 
This occurs in perhaps ten per cent, of all labors. 

Hemorrhage of the second degree is that which comes in pro- 
fuse gushes, and does not yield at once to abdominal pressure, 
but requires the use of cold or hot applications for its arrest, 
and even then, perhaps, manifests a disposition to return. 

Hemorrhage of the third degree includes dangerous bleedings, 
wherein the loss is excessive, and the prostration profound.* 

The Causes of post-partum hemorrhage are various, and as 
an indispensable bases for intelligent treatment, require thor- 
ough study. 

1. Among the indirect or predisposing causes we may men- 
tion precipitate labor. It is not altogether clear why a uterus 
which has expended' but a part of its nervous energy in expul- 
sive effort should become atonic, and bleed profusely, as soon 
as labor is brought to a close, and yet clinical experience teaches 
that it is a relatively frequent occurrence. Very likely the effect 
is produced by temporary exhaustion, arising from the intensity 
of the labor while it lasts, muscular inertia following here, as it 
does elsewhere, upon the heels of violent exertion. Contractions 
may be remarkably powerful, but if not long continued, vital 
force is sustained. In rapid labor many times there is scarcely 
any real intermission between the pains, and occasionally but 
slight remission, as the result of which strain, exhaustion event- 
ually results. 

2. Following unduly-prolonged labor we sometimes get a sim- 
ilar condition. Contractions having been forcible, perhaps, but 
intermittent, action is well sustained; but want of relative pro- 
portion between the foetus and the pelvis, or the existence of 
some mechanical obstacle, resists advance for so long a period 
that inertia becomes a sequence. Action in such cases can gen- 
erally be sustained for a long time, but the uterine muscles, like 

* Dr. Barnes has given us a very scientific and practical distinction between 
the intensity of symptoms, dividing them into three degrees which correspond 
with those above described. In hemorrhage of the first degree, the diastaltic 
function is maintained intact, but its action is disordered; in that of the second 
degree, the diastaltic force is markedly diminished ; and in that of the third, 
the diastaltic force is suspended. (Intermit. Med. Congress.) "Am. Jour, Obs." 
vol. xiv, p. 927. 



causes. 487 

similar structures in other parts, must, after long and vehement 
effort, have a prolonged period of rest. Labor being completed, 
and the stimulus by which the uterus has been provoked to 
action removed, it falls into atony at an unfavorable moment, 
and is not easily aroused to renewed activity. Labor, in point 
of duration, presenting either extreme, should then be regarded 
as a predisposing cause of post-partum hemorrhage. 

Beside the direct hemorrhage sometimes resulting from cer- 
vical rupture, there is no doubt that the accident occasionally 
indirectly produces uterine relaxation, and consequent hemor- 
rhage. This is probably not so pronounced respecting the pri- 
mary, as the secondary, form of post-partum bleeding. It has 
been shown by Emmet and others, that proper involution of the 
uterus after labor is embarrassed or prevented by cervical fis- 
sure. The uterine cavity being accordingly more capacious than 
normal, exciting causes combine to bring about congestion of 
the organ and consequent blood-loss. 

Flaccidity of the uterus after labor, and the bleeding result- 
ing from it, are, doubtless, often the consequence of slovenly 
practices, — a neglect of those details which should be matters of 
routine in every case. Delivery is suffered to take place while 
the bladder is distended with urine; the extended head is per- 
mitted to obstruct parturition for an indefinite time without any 
attempt at rectification; the practice which nearly all concur in 
commending for every case, namely, pressure on the fundus uteri 
during foetal expulsion, and after, is totally disregarded; or, fin- 
ally, the placenta is prematurely extracted. 

Constitutional dyscrasise account for a small percentage of 
cases. There is what has been termed the hemorrhagic diathe- 
sis, or hemophilia, which strongly predisposes to flooding. This 
is generally understood to depend on an abnormal condition of 
the circulating fluid, which favors its escape from the blood ves- 
sels, whether ruptured or not. There is a condition closely 
allied to this, wherein post-partum bleeding depends, not so 
much on an abnormal state of the blood itself, as upon constitu- 
tional predisposition to lax muscular tone. Such women have 
been termed "bleeders," inasmuch as, though sometimes appar- 
ently well nourished and vigorous, they suffer from floodings in 






488 POST-PARTUM HEMORRHAGE. 

repeated confinements to the extent of producing syncope and 
excessive exhaustion. 

Repeated child-bearing predisposes to the accident, it rarely 
occurring in first labors. 

The proximate, efficient causes, are first, and most frequently, 
uterine atony, flaccidity, inertia. 

In general, we find after expulsion of the foetus and placenta 
the uterus contracting into a globular-shaped mass which is felt 
in the hypogastrium, and which from its firmness and form has 
been termed the cannon-ball contraction. Such firm condensa- 
tion compresses the large blood-vessels of the organ, thereby 
effectually preventing loss, and rapidly hastening permanent in- 
volution. It is clear that this favorable state is brought about 
by the muscular tone which the organ still maintains, despite 
the severe strain to which it has been subjected. Xow, when, 
from any cause, this firm condensation of the blood-loaded 
organ fails to take place, the gaping vessels, at the site of pla- 
cental attachment, encounter nothing to restrain a free escape of 
the warm life-fluid which they contain. 

Probably ninety-eight per cent, of all cases of post-partum 
hemorrhage owe their immediate origin to this condition of the 
uterus, and hence it ought never to be out of mind in the con- 
duct of labor. 

There sometimes exist obstacles to the proper contraction of 
the womb when delivered of the product of conception. A large 
accumulation of urine may interfere materially, not only by di- 
rect encroachment upon the space afforded the pelvic organs, 
but also by sympathetic action. Attention to the bladder dur- 
ing and after labor is a matter which young practitioners, before 
they have acquired routine habits, are extremely prone to neg- 
lect. 

Tumors, generally fibroid, may thicken the walls, or en- 
croach on the cavity of the uterus, thereby preventing a com- 
plete, safe, and equable condensation of the organ, and exposing 
the woman to serious, perhaps fatal, loss. 

In certain instances there is hemorrhage escaping the vulva, 
not very profuse at any time, but continuous, though the uterus 
is firmly contracted. Failing to subdue it by ordinary means, 
we learn, on careful examination, that it proceeds from a lacera- 



PBEMONITORY SYMPTOMS. 489 

tion of tissue involving a blood-vessel. The circular artery of 
the cervix is sometimes ruptured during passage of the foetus, 
giving rise to considerable sanguineous flow. The vestibule, 
which suffers a solution of continuity oftener than is generally 
supposed, occasionally bleeds profusely from its lacerated sur- 
faces. 

Premonitory Symptoms.— Post-partum hemorrhage some- 
times gives notice of its approach, but the signs are so ambigu- 
ous that they usually fail to be understood, and hence are of 
trifling avail. Short, sharp pains, followed by complete uterine 
relaxation, are said generally to presage the ill-occurrence. 
Some light is shed on the probabilities by an acquaintance with 
the woman's history, and by observation of her bodily habit. If 
she gives an account of previous bleedings, whether post-partum 
or other; if menstruation has been habitually profuse; and final- 
ly if the tissues of the body give general evidence of lack of 
tone, we have reason to fear hemorrhage after delivery. 

A rapid pulse was formerly regarded as a highly suspicious 
symptom, and, so long as it continued, the woman was thought 
to be in imminent danger of the accident under consideration. 
The same opinion is still held by many, but it appears to have 
iittJe ground in clinical experience on which to rest. Dr. J. 
Ashburton Thompson * has made extensive and minute observa- 
tions, and as a result thereof has been led to believe that " these 
notes justify a contradiction of the bare assertion that a pulse 
which beats at or about a hundred shortly after labor prognosti- 
cates inertia of the uterus. * * * These notes show that in 
fact I have disregarded the pulse rate as a prognostic, or indica- 
tion, of my patient's safety from hemorrhage." Dr. M. M. 
Bradley f found in 300 cases that the pulse was from 50 to 130 o 
" From these observations," he says, " I am not inclined to 
attach much importance to the pulse-rate, either as a sign of 
danger, or of post-partum hemorrhage." 

The degree of blood-pressure very likely has some influence 
to produce and maintain hemorrhage from the uterus after la- 
bor, and it is a physiological fact that with high arterial tension 
we most frequently have a pulse of but moderate rapidity. 

* " Obstet. Jour." vol. v., p.' 785.1 
. f Ihid, vol. vii, p. 556. 



490 POST-PAETUM HEMORRHAGE. 

General Symptoms. — Hemorrhage sets in as a rule soon 
after expulsion or extraction of the placenta, and nearly always 
within the forty-fiye minutes immediately succeeding. Occa- 
sionally it begins when yet the secundines remain undelivered, 
while the attendant is giving the child necessary attention. 
When so occurring, the placenta is generally observed to be at 
the vulva, its separation from the uterine walls having prepared 
the way for bleeding. 

If the hand rests upon the fundus uteri, as it ought in every 
case, at this stage of delivery, contraction, which at first may 
have been good, is observed to relax, and the womb which was 
easily felt while in a condensed form, now escapes, so that its 
outline cannot be clearly defined. It will be understood that 
pressure upon the fundus is not necessarily made by the physi- 
cian, as he has other duties that cannot be delegated to a nurse, 
but the latter person, or even the woman herself, under suita- 
ble direction and supervision, may exercise the necessary com- 
pression. It is when the hard globular contraction ceases, that 
danger of serious loss of blood begins, and at such a time, espe- 
cially in multipara, we do well to be on our guard. Occasional 
examination should be made, either by touch or vision, when 
there is any reason to suspect an unusual flow. To make sure 
of accurate knowledge concerning blood-loss after delivery, it is 
Well at once to apply a clean napkin, and then, by inspecting 
this, we can easily determine with approximate certainty, the 
amount of flow. 

The bleeding generally begins suddenly, and often ceases as 
suddenly. There may be but a single gush, or one may succeed 
another, and rapidly reduce the woman. Sometimes the flow is 
comparatively passive, but exceedingly persistent, so that in half 
an hour there will be great depletion. In bad cases the blood 
runs in a torrent, and rapidly drains the system. 

In concealed hemorrhage after delivery, the womb, though 
perhaps at first firmly contracted, becomes flaccid; an impedi- 
ment, frequently in the form of a coagulum, obstructs the flow; 
the uterus offers but feeble resistance, and bleeding goes on 
within. In case the hand is kept properly applied to the ab- 
domen, and search made for the uterus by firm kneading, when 
it escapes the feel, there is little likelihood of dangerous con- 



SYMPTOMS. 491 

cealed hemorrhage. Bad examples of hemorrhage are met in 
those cases wherein abdominal pressure is neglected, or the 
bleeding begins a considerable time subsequently to labor, after 
watchful care has ceased. There being no outward indication 
of the flow, its occurrence is not often recognized until the effects 
of depletion are manifested in the countenance and feelings of 
the woman. She will complain of great exhaustion, and may- 
fall into a state of syncope. Alarmed at her condition, the phy- 
sician feels her wrist only to find the pulse feeble and fluttering, 
or not to discover it at all. The hand on the abdomen obtains 
clear evidence of the uterus distended with blood, while firm pres- 
sure causes it to gurgle forth into the bed. 

There is a spurious form of concealed hemorrhage that is 
manifested as a result of professional ignorance or inattention. 
The ordinary precautions are disregarded — the fundus uteri is 
left uncovered by the hand, none of the signs of bleeding 
are watched for, and the accident is far advanced before the 
guilty attendant is aware of its existence. Blood pours forth 
noiselessly, while the patient, reposing the utmost confidence in 
the skill of her physician, rests quietly, until she feels a deathly 
sensation stealing over her, when she calls for help. On throw- 
ing up the bed covering there is found, to the consternation and 
shame of her dull attendant, a great pool of blood. 

The symptoms of post-partum hemorrhage differ mainly in 
intensity. There may be but a brief flow, producing no special 
effect on the woman, and this is the sort which the young practi- 
tioner so often meets, and which responds readily to a dose of 
ipecac, or belladonna. In other instances, happily infrequent, 
the flow begins like the other, is a little more free, and is in- 
disposed to surrender to the remedies mentioned, or to any other 
potentized drug, but ultimately ceases, either from natural 
causes, or manual treatment combined with refrigeration. In a 
third class of cases, the flow comes suddenly, and spurts from 
the vulva like water from a pump, waits for nobody, is unmind- 
ful of drugs, does not yield to either cold or heat, and in the 
absence of proper treatment hurries the patient on through the 
various stages of loss, down to death. The extremities become 
cold and damp; the countenance gets pale and ghastly; the pulse 
rapid and small— perhaps intermittent; the limbs weary, and 



4:92 POST-PABTUM HEMOKEHAGE. 

yet restless. There is sighing respiration, dimness of vision, 
and syncope. Later the whole body, and even the brecth, grows 
cool; intense restlessness and jactitation, supervene; and death 
ends the scene. 

Primary hemorrhage occurs soon after labor, generally within 
the first hour, and for this reason, among others, the physician 
ought to remain with his patient during that time. Post-partum 
hemorrhage in general is of the primary variety. 

Secondary, Hemorrhage after labor at full term, is generally 
consecutive upon other symptoms which indicate a retention in 
utero of a fragment of the secundines, or a coagulum; the exist- 
ence of interrupted-involution, or of malposition of the organ. 

When the placenta is delivered in any case of labor, it ought 
to be carefully inspected to make sure that no part is left be- 
hind. If much traction force is applied to the cord, the bulk 
of the organ and membranes may be brought away, while a por- 
tion, large or small, is left behind. Disintegration of such a 
fragment usually takes place, and the detritus passes off in the 
lochia, without disturbance; but in other cases, hemorrhage re- 
results. 

There is developed in rare instances a supplementary placenta, 
placenta succeniuriata, the connection between the organs being 
marginal, and the smaller, or secondary one, may be left behind. 
Any examination but the most minute, would scarcely be suffi- 
cient to disclose the fact, and it comes to light only when hem- 
orrhage, or septic symptoms with offensive discharges, lead to 
uterine exploration. 

In few cases of secondary hemorrhage do we find the flow 
extremely profuse. It is alarming on account of the period when 
it occurs, the time for flooding presumably being past. Still, 
the patient occasionally evinces signs of great depletion, and 
may present threatening symptoms. 

During the first few hours and days after delivery, even in 
normal cases, the woman is in a state favorable to the develop- 
ment of a variety of ills, and, among them, sudden and profuse 
blood-loss. A powerful disturbance of the emotional nature is 
sometimes an exciting cause. Great joy, anger, or fear is capa- 
ble of giving rise to serious, even fatal hemorrhage. Instances 



TEEATMENT. 493 

of the kind have been placed on record, and stand as reminders 
of possible occurrences. 

Prognosis. — The remote effects of excessive loss, some of 
which have been mentioned in another chapter, should not be 
forgotten. A train of ills is liable to follow, and make misera- 
ble an otherwise happy life. The immediate prognosis in most 
cases is favorable. The great majority of women do well after 
flooding, and some authorities have accordingly taught that it is 
more alarming than dangerous. There are always entailed a few 
days of suffering from headache, prostration, and, may be, vom- 
iting and purging. Then follow convalesence, and, in favorable 
cases, perfect restoration. But the exceptions occasionally ob- 
served, in respect to both immediate and remote effects, should 
give to the favorable prognosis an air of seriousness. 

The more remote results of hemorrhage are insanity, phleg- 
masia, pelvic inflammations and general peritonitis. 

Treatment. — Preventive treatment is of the utmost conse- 
quence, and yet it consists in the adoption of but few special 
rules. The directions given for the conduct of normal labor 
are generally sufficient of themselves, when scrupulously ob- 
served, to prevent the occurrence of untoward symptoms after 
delivery. If we make it a rule of practice to attentively observe 
the progress of the head through the pelvic cavity, and see that 
it follows those positions and movements which are favorable to 
ready performance of the mechanism of labor, which in their 
turn preserve the uterus from undue exertion ; if we keep the blad- 
der empty; if, upon expulsion of the child, we apply an assist- 
ant's hand to the contracting uterus, and keep it there, not only 
to the close of the third stage, but for a considerable time there- 
after; if, finally, we combine Credo's method of placental de- 
livery, with slight traction, if necessary, on the cord, we will 
rarely indeed have thrust upon us for treatment a severe case of 
hemorrhage. Crede's method of placental delivery commends 
itself, with much emphasis, to our adoption.* 

* We may judge of the improvement effected by the introduction of Crede'si 
plan of treatment, from the statistics of Bossi, (Wiener Mediciniselie Wochen- 
schrift, Nos. 30-32, 1863,) who says that, in the Clinical wards at Vienna, 
where the new method was in every instance adopted, the eases of post part* 
urn hemorrhage amounted only to 1.47 per cent., while in the other wards, 
where the old line of practice was followed, they amounted to 3.52 per cent. 



494 POST-PAKTUM HEMORRHAGE. 

Occasionally we will feel called upon to adopt more specific 
treatment for the prevention of impending danger. The woman 
perhaps is a "bleeder," and gives a history of a previous flood- 
ing of a most violent type; or, it may be, without any such his- 
tory, the uterus, from exhaustion of its overworked powers of 
endurance, toward the close of the propulsive stage manifests 
unmistakable symptoms of inertia. In either case, ordinary 
routine conduct may prove inadequate to avert the threatened 
accident. In such occasional instances justice to our patients 
demands that we bring to bear forces better able to meet and 
temper the crisis. The pathological condition of the uterus, 
which we fear will be developed as soon as that organ has been 
emptied, is flaccidity of its walls, giving free escape to the blood 
circulating within. Now, if there is any remedy which is capa- 
ble of stimulating contraction, without at the same time seri- 
ously harming the patient, in the name of humanity it ought to 
be given. Ergot of rye is capable of doing this very thing in 
the great majority of cases; but to get the effect, it must be ad- 
ministered in appreciable quantities. A single dose of one 
drachm of the fluid extract ( Squibb' s preferred) may be given 
by the mouth, or ten drops of the same may be injected deep 
into the tissues. The latter mode of administration is to be pre- 
ferred, as when so employed the drug acts with greater celerity, 
certainty, and force. 

The time to administer ergot as a preventive of post-partum 
hemorrhage, is when the head lies at the pelvic outlet. Deliv- 
ery may be effected by the forceps, or by the natural efforts, and 
the placenta subsequently removed. By the time this is done 
the drug will have produced its effect, and firm uterine contrac- 
tion will be established. 

Those who fear to employ ergot in the manner prescribed, or 
who look upon such an act as reprehensible in a homoeopathic 
practitioner, will prefer to search eagerly for characteristic 
symptoms of some attenuated drug. Special indications may 
be found ion Pulsatilla, china, caulophyllum, gelsemium, ustilago, 
or even secale; and through its employment the desired end may 
be attained. 

Dr. McClintock advocates rupture of the membranes. "I 
have adopted the precaution of rupturing the membranes," he 



TREATMENT. 495 

says, "on very many occasions, and am fully persuaded it is a 
most valuable, and always a feasible auxiliary in the prevention 
of flooding after delivery." Dr. Dewees accounted it the prin- 
cipal means to be relied on for the purpose of averting the ac- 
cident.* 

In addition to these means, it is advisable to immediately ap- 
ply the child to the breast. The close sympathy between the 
breasts and the uterus gives significance to the act. 

The room occupied by the patient should be cool, and free 
from a company of noisy, excited women. Let everything be 
done decently and in order, without confusion or agitation. The 
physician, above all, in such an emergency, should keep his emo- 
tional nature in perfect subjection. He must not stop to pon- 
der possibilities, or probabilities, or to reflect upon his immense 
responsibilities, for these will be patent enough. He is the pre- 
siding genius, and the result largely depends on his executive 
ability. 

Hemorrhage of the First Degree. — Under fear, or excite- 
ment, the young practitioner is liable to adopt too vehement 
practices for the arrest of hemorrhages of the first degree. It 
should be remembered that the last stage of labor is always 
accompanied with more or less blood-loss, and if not remark- 
ably profuse or prolonged, it need excite no alarm. To apply 
ice and snow to the abdomen, or carry it into the vagina; to dash 
cold water over the abdomen, and to pass the hand into the 

* The following hints on the prophylaxis of post partum hemorrhage, by Dr. 
Pryor (Am. Jour. Obs., vol. x., p. 698.) : " It is not at all infrequent that we 
are called to attend women who have had hemorrhage following their previ- 
ous confinements, and who look forward to the close of gestation with fear and 
trembling, the predisposing causes of hemorrhage during pregnancy and partu- 
rition being intensified by the hemorrhagic diathesis. By gaining their entire 
confidence with the assurance that we possess means of prevention almost in- 
fallible, we gain an advantage of no little value as a means of prophylaxis. 
Take a case where you have reason to apprehend, or where hemorrhage has 
actually set in, apply a ligature or bandage (about an inch in width 1 ) around 
each extremity, as close to the body as possible, drawing them sufficiently 
tight to arrest the return of venous blood without materially affecting the ar- 
terial circulation, then proceed with your other mechanical as well as 
medicinal agents." Dr. Pryor puts great confidence in this mode of prevent- 
ive treatment. 



496 POST-PARTUM HEMORRHAGE. 

womb for the purpose of checking such a flow, is not only un- 
necessary, but positively unwise. The fundus uteri should be 
pressed firmly with the palm of the hand, which may be made 
cold by dipping in cold water, and in a moment the flow will 
cease. We should not neglect this procedure for the purpose of 
administering a remedy, however well indicated. The most 
effective treatment must be adopted, or a slight loss may be 
transformed into a profuse hemorrhage. The womb in such 
cases seems a little undecided between contraction and expansion, 
and requires but a suggestion to determine its choice. 

In this same class we may properly include that variety of 
hemorrhage which depends on a laceration of the cervix or ves- 
tibule. The flow is not profuse, but is persistent; and firm con- 
traction of the uterus is observed to have little effect on it. The 
bleeding vessel sometimes requires a ligature, in order to apply 
which to the cervix, the uterus must be drawn down by a tenac- 
ulum, or volsella, and the vessel secured. Torsion will answer 
just as well it properly made in accordance with the usual di- 
rections, viz: to seize the vessel firmly and make two or three 
turns with the forceps. The application of cold, or if necessary 
a styptic like the perchloride of iron, will usually answer every 
purpose. The vestibular bleeding is more easily controlled than 
the cervical; a piece of ice or snow applied to the part for a 
moment or two being sufficient to arrest it in nearly all cases. 

Hemorrhage of the Second Degree.— The treatment for 
flooding of the second degree is first, the use of cold. Cold 
water is always procurable, and the hand may be plunged into 
it, held there for a moment, and placed on the abdomen with 
firm pressure. If this does not excite contraction and arrest of 
the hemorrhage, the other hand may 'be similarly dipped and 
then carried into the vagina. Bepeat the latter movement a num- 
ber of times, if required. 

With the fingers m the vagina, uterine contraction is some- 
times excited by irritating the cervix uteri. Should anything be 
discovered at the os, as, for example, a fragment of placenta, or 
a coagulum, it must be removed. 

The medicinal treatment for such an accident ought to be re- 
garded as subsidiary to the mechanical, arid yet must not be 
despised. The special indications for remedies will be given at 



TKEATMENT. 497 

the close of this chapter. There can be no reasonable doubt of 
the efficacy of the closely affiliated remedy in regulating the 
disturbed vital action, and thereby subduing post-partum hem- 
orrhage; but in view of the extreme liability to error in our 
choice of remedies, and the certainty with which other measures 
can be employed, the latter should first be applied, and then re- 
inforced, if necessary, by the former. 

Hemorrhage of the Third Degree.— Hemorrhage of the 
second degree by mismanagement or neglect, may exceed its 
bounds and merge into that of the third. In managing the lat- 
ter, firm pressure upon the fundus uteri must not be neglected, 
for really this is the most important part of treatment. Every 
effort should be made to keep the uterus under the hand, and 
well depressed toward, or into, the pelvic cavity. No decided 
intermissions should be allowed, but a certain amount of knead- 
ing will be beneficial. 

Cold water may be used as above indicated, or instead of it, 
ice may be applied to the abdomen, and introduced through the 
vulva, or, if thought requisite, even into the uterine cavity. 
Snow may be similarly used. Some have recommended pouring 
cold water from a height on the abdomen, but the advisability 
of so doing is questionable, save in the case of warm, vigorous 
women. Such refrigeration would be too great for others. Much 
harm may be done by an injudicious use of cold. Let it be 
remembered that the action of refrigerants derives its efficacy 
mainly from the first impression which it makes, and it ought 
not to be long-continued. 

The other extreme of temperature is just as fruitful jin good 
results. Applied to the lumbo-sacral region, hemorrhage from 
the womb is sometimes speedily arrested by it. Within the last 
decade, hot water has been found a most efficient means for con- 
trolling uterine hemorrhage, when injected directly into the 
uterine cavity. There is little or no danger connected with the 
operation, provided there is no obstacle to free escape of the in- 
jected fluid. Immediately after labor, the os uteri is so open 
that the water can easily flow away, and the uterus at such a 
time will safely tolerate more than at any other. If the opera- 
tion is undertaken, the nozzle of a fountain syringe may be 
passed through the os uteri, and up well to the fundus, against 



498 POST-PAETUM HEMOEEHAGE. 

which the stream should be directed. Care ought to be exer- 
cised to prevent the introduction of any atmospheric air. It is 
said by many who have adopted this mode of treatment, that as 
soon as the stream of water, at a temperature of 115° to 120°, 
strikes the uterine walls, contraction is excited, and the hem- 
orrhage ceases. There is, however, some adverse testimony. Dr. 
Stedman reports having failed to arrest a violent flow by means 
of it, being finally driven to the use of perchloride of iron. Hot 
water doubtless arrests uterine hemorrhage by a double action, 
namely: by its styptic, and by its stimulant effects. 

One of the very best expedients for overcoming such floodings 
is to introduce the hand into the womb. Some entertain a mor- 
bid fear to perform such an act, but the fact is that, if gently 
done, it is almost devoid of danger. The soft pelvic tissues 
have been contused and lacerated by ruthless operators, but the 
considerate will be guilty of no such harshness. 

In these instances of dangerous hemorrhage, the hand is 
carefully passed through the vulva and os uteri, until it reaches 
the uterine cavity. Here, instead of firm tissues, and a con- 
tracted space, it finds remarkable flaccidity and considerable 
room. The walls of the organ seem peculiarly soft and yield- 
ing, being "folded together," as Cazeaux graphically remarks, 
"like a piece of old linen." 

The very presence of the hand communicates a stimulus to 
the uterus, which is generally sufficient to excite contraction. 
But this is not the only result which may be obtained by the oper- 
ation. The relaxed state of the organ is many times dependent 
on the existence in utero of coagula, and firm condensation can- 
not be acquired and maintained until they are removed. Ac- 
cordingly it is set down as one of the most important principles 
of treatment, to thoroughly evacuate the uterus. 

Ergot has been recommended as a remedy for all forms of 
dangerous uterine hemorrhage, and yet there appears to be little 
place for it here. Hemorrhage of the third degree generally 
runs its course too rapidly for us to expect much aid from this 
remedy, especially when administered through the mouth, and 
the other degrees of hemorrhage do not require it. 

Despite the treatment above recommended, flooding may con- 
tinue, or be no more than temporarily subdued, and for such 



TREATMENT. 499 

cases we have further treatment which has many times availed 
to save life. Styptic intra-uterine injections of various sub- 
stances have been recommended, but that which has afforded the 
best aid is the perchloride of iron.* This is used in strength 
varying from one part of the iron to ten of water, to equal parts 
of each, and even stronger. It should be thrown into the uterine 
cavity, the point of the syringe being carried nearly to the fun- 
dus of the organ. Before doing so, however, the uterus ought 
to be cleared of coagula and fragments of placenta. The action 
of the iron is to coagulate the organic principles of the blood, 
and at the same time to have an astringent effect on the blood 
vessels and surrounding tissues. This is a dangerous expedi- 
ent, and must never be resorted to save under the demands of 
inexorable necessity. 

The supply of blood to the pelvic viscera may be modified by 
firm pressure on the abdominal aorta. This large blood vessel 
can be easily felt by depressing the abdominal walls on the left 
side of the spinal column. Compression ought not to be long 
continued, and should be made with great care. A temporary 
arrest of the flow will give time for the formation of coagula in 
the ruptured vessels, and aid greatly in permanently arresting 
hemorrhage. 

The caution elsewhere given may be repeated here — the phy- 
sician must beware how he interferes in those cases^where the 
loss has been excessive, but has temporarily ceased. It is the 
last ounce of blood that kills. It may be that syncope has en- 
sued, and the feeble circulation which characterizes the condi- 
tion has led to the formation of coagula. To excite the circula- 
tion, or to interfere with the clots, may awaken renewed flood- 
ing. Therefore withhold the hand, and attentively watch the 
case. Kenewed strength, or renewed hemorrhage, will indicate 
the moment for interference. The woman rallying sufficiently 
to bear the strain, we may empty the uterus and stimulate per- 
manent contraction. The hemorrhage returning, we may take 
like action to effectually arrest it. Therefore, when there is 
syncope, we should not hastily begin stimulation, but guard 
against complete cardiac failure. Should dangerous symptoms 
ensue, stimulate well. The hypodermic administration of sul- 
phuric ether has proved extremely efficacious. 



500 POST-PAKTUM HEMOEKHAGE. 

The Treatment for Concealed Hemorrhage, Post-Partum, 

differs in no material respects from that already given for ex- 
ternal bleeding. As soon as the condition is recognized, the 
distended uterus must be compressed with the hand from above, 
and the discharge of its contents enforced. The hand should 
then be introduced, and all retained coagula removed. 

Secondary Hemorrhage requires "the application of similar 
principles of treatment, it being quite essential that the womb 
be well emptied. This form of flow, depending, as it does in 
many cases, on retained parts of placenta, will generally require 
introduction of the hand, though if manifested at a considerable 
interval from labor, the fingers only can be used. After remov- 
ing a retained fragment of the after-birth, it is well to wash out 
the uterine cavity with a mild solution of carbolic acid, or some 
other disinfecting fluid. 

For the sub-involution existing in such cases, secale cornutum 
2 x or 3 x is probably the best remedy. Trillium or trillin is 
nearly as efficacious. Other remedies may be indicated by 
special symptoms. 

The following summary of treatment will be found con- 
venient: 

Treatment. — Preventive. — Observe the rules for the conduct 
of normal labor. 

Eupture membranes before complete dilatation. 

Give ergot by the mouth, or by hypodermic injection, just be- 
fore the close of the second stage of labor. Do not remove the 
placenta too soon. If not naturally expelled, combine expres- 
sion with extraction for its delivery. 

Curative. — General. — Lower the head, and elevate the hips. 
If necessary, practice auto-transfusion. 

Have the room cool and quiet. 

Preserve a composed air. 

Primary Hemorrhage — 1st Degree. — Press on fundus uteri 
with cold hand. 

Avoid vehement practices. 

2d Degree. — Press on the fundus uteri. Irritate the cervix 
uteri, and, if necessary, introduce the hand. Give the indicated 
remedy. 



TREATMENT. 501 

3d Degree,— Tress on the fundus uteri. Eefrigerate (in par- 
ticular cases). Introduce the hand into the uterus, and remove 
all clots, etc. Administer indicated remedies. Use hot water 
injections, and heat to the lumbo-sacral region. Kelentingly 
inject styptics. Compress abdominal aorta. Do not needlessly 
disturb clots when the hemorrhage has temporarily ceased. Do 
not stimulate much unless necessary. 

Curative. — Secondary Hemorrhage. — Empty uterus, and 
treat as other forms. 

Administer suitable remedies. 

Homoeopathic Therapeutics. — Ipecac is used more fre- 
quently, perhaps, than any other remedy in attenuation, for the 
arrest of post-partum hemorrhage. It is indicated by a profuse 
flow; blood bright red, or clotted. 

Belladonna is said to be an excellent remedy; and, like ipecac, 
capable of controlling bleeding without mechanical or manual 
aid. The chief symptoms which call for it are profuse flow of 
bright, red blood, which speedily coagulates. The blood feels hot 
to the parts. 

Sabina is indicated by a bright red flow, sometimes clotted. 
It is often efficacious for profuse bleeding, with no other special 
indication. It is particularly serviceable when the flow is de- 
pendent on a retained fragment of the secundines. 

Secede is called for by hemorrhage, especially in thin, cachectic 
women, when the flow is dark, and coagulates slowly, or not 
at all. 

Crocus, when the flow is dark and stringy; worse from the 
least exertion. 

Pulsatilla and sabina are the best remedies for secondary 
hemorrhage when it depends on retained fragments. 



502 



RETAINED PLACENTA. 



CHAPTER XYII. 



Fig. 218. 



Difficulties and Dangers Arising in the Third 

Stage Of Labor.— (Continued.) 

Retained Placenta. — The placenta is often retained through 
unwise treatment of the third stage of labor. Without reference 
to efforts at expression, such as we have described as appropri- 
ate in every case, mere traction is sometimes made on the cord 
with the effect to invert the placenta, and bring it to the os uteri 
in such a way as to prevent the entrance of atmospheric air, and 
make the retentive powers of the uterus ex- 
tremely difficult to overcome. Crede's meth- 
od is sometimes improperly attempted, and 
instead of the uterus being pushed down- 
wards and backwards in the direction of its 
long axis, the fundus is pressed downwards 
and forwards against the symphysis pubis. 

Really adherent placenta is a comparatively 
rare occurrence; but there are occasionally 
well marked examples of it, traceable to for- 
mer endometritis.* 

Irregular contractions of the uterus are in 
some instances the efficient cause of retention. 




Irregular uterine 
(hour-glass) con- 
traction, with re- 
tention of the pla- 
centa. 



Treatment. — When the placenta cannot be 
gotten away by firm pressure of the uterus, 
coupled with judicious traction on the cord, 
within what may be regarded as a reasonable time, other meas- 



:: When Crede introduced his method, he declared that r " the spectre of ad- 
herent placenta would he scared away." 



TKEATMENT OF EETAINED PLACENTA. 503 

ures must be employed for long retention is a dangerous 
complication. 

When the placenta is retained, it sometimes becomes a point 
of great nicety to decide when yon are to operate manually, and 
when you are not. 

Before resorting to artificial separation and extraction, we 
should for a time try the effect of remedies, fitly chosen, and 
meanwhile keep the case under attentive surveillance. The 
most suitable remedies are Pulsatilla and china, and they may 
be given singly or in alternation. Should special indications be 
found for any other remedy, let it be given. If the retention is 
not overcome by these various measures within an hour, we be- 
lieve it is wise, in the absence of contra-indicating symptoms to 
pass the hand partially or wholly into the uterine cavity for the 
purpose of removing the after-birth. A digital examination will 
indicate the advisable course to follow. The four fingers may 
be entered, if necessary, and if a border of the placenta can be 
reached, it should be drawn down, when, if no morbid adhesions 
exist between that organ and the uterus, compression of the 
latter and slight traction on the cord will suffice to secure de- 
livery. Injection of the umbilical cord, to its full capacity, will 
sometimes serve to arouse the uterus to contraction, and produce 
separation of the placenta. 

If such efforts fail, the fingers may be pushed onward into 
the uterine cavity, and separation undertaken. By begin- 
ning at the margin, we will generally soon succeed in our endeav- 
ors. In some cases, however, small fragments of the organ are 
so firmly adherent as to necessitate leaving them to be dis- 
charged with the lochia. If every part of the placenta is adher- 
ent, a thickened border should be selected as the point for com- 
mencing the detachment. 

If irregular uterine contractions are found, they should be 
overcome by manual dilatation to a degree sufficient to admit of 
separation and removal of the secundines. 

After the adhesions are overcome, the placenta and hand 
should not be withdrawn unless the uterus is disposed to con- 
tract, and even then the organ ought to be followed down with 
the abdominal hand. 

The entire operation should be performed without hurry, as 



504 



INVERSION OF THE UTERUS. 



otherwise the uterine tissues may suffer from unnecessary trau- 
matism, and, upon its completion, should be succeeded by a 
warm disinfecting enema. 

Acute Inversion of the Uterus. — This, by no means fre- 
quent accident,* consists of a turning inside-out of the uterus, 
so that in well-marked cases the mucous surface of the fundus 
protrudes through the os into the vagina, or is even prolapsed 
through the vulva. In other cases the action does not proceed 
to that length, but the fundus is only depressed a little way, as 
represented in figure 219, and we accordingly have complete and 
incomplete inversion. 

Fig. 219. Fig. 220. 





Incipient inversion. 



Showing the commencement of in- 
version of the cervix. 



Causes. — There is no doubt that the accident in a certain 
number of cases has resulted from immoderate traction made on 
the umbilical cord for the purpose of extracting the placenta. 
A similar cause operates when the umbilical cord is very short, 
and expulsion of the foetus produces traction on it. Also, rarely, 
when birth of the child takes place suddenly with the woman in 
an upright position; the fundus being pulled down by the strain 

* It was observed but once" in* 190,800 deliveries at the Rotunda Hospital, 
London, and many physicians m extensive obstetrical practice never see a 
case. 



SYMPTOMS. 505 

on the cord. " It may arise also from inattention to the condition 
of the uterus while pressure is being exerted on the fundus ute- 
ri for the purpose of delivering the after-birth. If the organ is 
relaxed, its fundus may be indented like a hollow rubber ball. 

Dr. Tyler Smith * believes that the accident may be occasion- 
ed by irregular uterine contraction, independently of every 
other circumstance. 

Inversion may begin at the cervix, instead of the fundus 
uteri, as pointed out by Duncan, and in some cases become com- 
plete. 

Symptoms. — Dr. Meadows, who has met two cases of the 
kind, gives the symptoms so clearly, and yet concisely, f tha ': we 
quote him here: "The symptoms of inversio uteri are gener- 
ally pretty well marked, and are, always, of a serious and alarm- 
ing character in proportion to the amount or degree of inver- 
sion; they have reference chiefly to the nervous system, which 
gives evidence of very severe shock. In the slighter cases there 
is great pain, of a dragging or bearing-down character, situate 
chiefly in the back and groins, with more or less hemorrhage — 
' the patient suffers under an oppressive sense of sinking, with 
nausea or vomiting, cold clammy sweats, feeble, fluttering, or 
nearly extinct pulse, faintings, or even convulsions.' These are 
the kind of symptoms which always occur to a greater or less 
extent; but ' the most universal symptom is a sudden exhaustion, 
which comes on immediately after the inversion.' The amount, 
both of the hemorrhage and of the pain, varies: they are great- 
er in the complete than in the incomplete version; and, as a 
general rule, though the symptoms are less severe in appear- 
ance in the latter than in the former, they are not so in reality, 
for the shock to the nervous system has .been so great that, in 
some instances, the patient has died almost immediately. 

" On examining the abdomen, we shall probably not be able 
to feel the uterus at all, while per vaginam a round hard tumor 
will be felt, which may be visible even beyond the external 
parts. It is of a bright red color, its surface being smooth and 
bleeding; the size of the tumor will vary with the amount of in- 
version, and partly also with the time which has elapsed since 

* " Lectures on Obstetrics," Am. Ed., p. 586. 
f " Manual of Midwifery," 4th Ed., p. 437. 



506 INVERSION OF THE UTERUS. 

it took place. In recent cases, there is generally a good deal of 
swelling, possibly from the return of blood being prevented by 
the narrow constriction of the now inverted os." 

Diagnosis. — The only condition with which acute inversion of 
the uterus is very liable to be confounded is that of uterine pol- 
ypus. From this it will be distinguished by the absence of the 
contracted uterus from the hypogastrium, and the utter inability 
to pass the uterine sound. Should the placenta remain adherent, 
as sometimes happens, it would serve to dispel any doubt con- 
cerning the inversion which might otherwise exist. 

Treatment. — The following we borrow from Playf air :* " The 
treatment of inversion consists in restoring the organ to its nat- 
ural condition as soon as possible. Every moment's delay only 
serves to render restoration more difficult, as the inverted por- 
tion becomes swollen and strangulated; whereas, if the attempt 
at reposition be made immediately, there is generally compara- 
tively little difficulty in effecting it. Therefore, it is of the 
utmost importance that no time should be lost, and that we 
should not overlook a partial or complete inversion. Hence the 
occurrence of any unusual shock, pain, or hemorrhage after de- 
livery, without any readily ascertained cause, should always lead 
to a careful vaginal examination. A want of attention to this 
rule has too often resulted in the existence of partial inversion 
being overlooked., until its reduction was found to be difficult or 
impossible. 

" In attempting to reduce a recent inversion, the inverted por- 
tion of the uterus should be grasped in the hollow of the hand 
and pushed gently and firmly upwards into its natural position, 
great care being taken to apply the pressure in the proper axis 
of the pelvis, and to use counter-pressure, by the left hand, on 
the abdominal walls. Barnes lays great stress on the importance 
of directing the pressure toward one side, so as to avoid the 
promontory of the sacrum. The common plan of endeavoring 
to push back the fundus first has been well shown by McClin- 
tock to have the disadvantage of increasing the bulk of the mass 
that has to be reduced, and he advises that, while the f andus is 
lessened in size by compression, we should, at the same time, 

*" System of Midwifery," Am. Ed., 1880. p. 439. 



TREATMENT. 507 

endeavor to push up first the part that was less inverted, that is 
to say, the portion nearest the os uteri. Should this be found 
impossible, some assistance may be derived from the manoeuvre, 
recommended by Merriman and others, of first endeavoring to 
push up one side, or wall of the uterus, and then the other, al- 
ternating the upward pressure from one side to the other as we 
advance. It often happens as the hand is thus applied, that the 
uterus somewhat suddenly reinverts itself, sometimes with an 
audible noise, much as an India-rubber bottle would do under 
similar circumstances. When reposition has taken place, the hand 
should be kept for some time in the uterine cavity to excite tonic 
contraction; or Barnes' suggestion of injecting a weak solution 
of perchloride of iron may be adopted, so as to constrict the uter- 
ine walls, and prevent a recurrence of the accident. 

" It is hardly necessary to point out how much these manoeu- 
vres will be facilitated by placing the patient fully under the 
influence of an anaesthetic. 

" There has been much difference of opinion as to the manage- 
ment of the placenta in cases in which it is still attached when 
inversion occurs. Should we remove it before attempting repo- 
sition, or should we first endeavor to reinvert the organ, and 
subsequently remove the placenta? The removal of the pla- 
centa certainly much diminishes the bulk of the inverted portion, 
and, therefore, renders reposition easier. On the other hand, if 
there be much hemorrhage, as is so frequently the case, the re- 
moval of the placenta may materially increase the loss of blood. 
For this reason, most authorities recommended that an endeav- 
or should be made at reduction before peeling off the after-birth. 
But, if any difficulty be experienced from the increased bulk, no 
time should be lost, and it is in every way better to remove the 
placenta and endeavor to reinvert the organ as#soon as possible. 

" Supposing we meet with a case in which the existence of in- 
version has been overlooked for days, or even for a week or two, 
the same procedure must be adopted; but the difficulties are 
much greater, and the longer the delay the greater they are 
likely to be. Even now, however, a well conducted attempt at 
taxis is likely to succeed. Should it fail, we must endeavor to 
overcome the difficulty by continuous pressure applied by means 
of caoutchouc bags, distended with water and left in the vagina. 



508 ASPHYXIA NEONATORUM. 

It is rarely that this will fail in a comparatively recent case, and 
such only are now under consideration. It is likely that by 
pressure applied in this way for twenty-four or forty-eight hours, 
and then followed by taxis, any case detected before the involu- 
tion of the uterus is completed may be successfully treated." 

Several cases are on record in which efforts at reposition were 
unsuccessful, but in which, nevertheless, spontaneous reposition 
subsequently took place. 

Suspended Animation, or Asphyxia Neonatorum. 

Asphyxia of the foetus may be brought about in several ways. 
While the child remains wholly in utero, its supplies of oxygen 
are received through the utero-placental circulation; but when 
expulsion has taken place, and in some cases even before it is 
completed, they are obtained in the usual manner through the 
pulmonary structures. Anything which may occur, then, during 
intra-uterine life, to interrupt the utero-placental circulation, and 
anything which may intervene, during complete or incomplete 
extra-uterine existence, to obstruct respiration, may give rise to 
asphyxia. Thus we have among the causes of intra-uterine 
asphyxia, premature separation of the placenta, compression, 
stenosis and torsion of the umbilical cord; and among the causes 
of extra-uterine strangulation, the presence of mucus and fluid 
in the throat and lungs. Long continued interruption of the 
foetal circulation, and the presence of mucus in the throat from 
premature respiratory efforts, are the most common causes. We 
should add, however, that piemature interruption, or lowering 
of the fcetal circulation, not only deprives the foetus of its nec- 
essary supplies, but the very interruption stimulates respiratory 
efforts, which result only in filling the lungs with mucus, blood, 
and liquor amnii, and thereby adding to the gravity of the case. 

" Experience has shown that pressure on the brain during la- 
bor may be attended by the most serious consequences to the 
child. It remains to be seen in what way these unfavorable re_ 
suits of cerebral pressure can be explained. It may well be 
doubted whether pressure upon the medulla oblongata so irri- 
tates it as to produce the first inspiratory movement; at any rate, 
prolonged cerebral pressure, through irritation of the vagus, 
slackens the pulse and diminishes the irritability of the medulla 
oblongata because the exchange between the maternal and the 



MORBID ANATOMY. 509 

foetal blood is impeded, and, consequently the blood circulating 
in the foetus is poorer in oxygen. By cerebral pressure, there- 
fore, the child becomes comatose, and this may assume such a 
degree that the usual irritations are no longer able to produce 
inspiratory movements. The child is exposed to such a danger 
by compression of the head within a contracted pelvis, or by 
the firmly compressed forceps."* Effusion of blood into the 
hemispheres is well borne by new-born infants; but effusion at 
the base of the brain is fatal. 

Morbid Anatomy. — Schultze describes two stages — asphyxia 
livida and asphyxia pallida^. In the first stage, tonicity of the 
muscles remains, and reflex movements are easily excited. The 
skin is dusky-red, the cutaneous vessels are turgid, and the eye- 
balls protrude. The heart beats slowly, but forcibly. Sponta- 
neous respiration is often set up, or can usually be easily excited. 
In unfavorable cases the child soon passes into the second 
stage. 

In the second stage, or asphyxia pallida, the child is anaemic, 
the body is cold and limp, and the sphincters are relaxed. Ke- 
flex movements cannot be excited. Pulsation is rapid and fee- 
ble. If inspiratory efforts are made they are feeble, and are not 
participated in by the facial, nasal, or maxillary muscles. Re- 
spiratory movements may, after a time, be established through 
artificial stimulation. 

Diagnosis and Prognosis. — SchultzeJ claimed to have prac- 
ticed auscultation of intra-uterine respiration with success, 
while many have heard the intra-uterine cry (vagitus uierinus). 
Diminished frequency and force of the foetal heart-sounds, per- 
sisting during the intervals between pains, indicates the begin- 
ning of asphyxia. When delivery has been partially effected, 
the failing pulse and the cyanosis give evidence of the condition. 
Dr. Garrigues§ reports a case of asphyxia wherein he practiced 
artificial respiration for a period of two and a half hours before 
the child made the first respiratory gasp. It died seven hours 

* Scheoedee. " Lehrbuch," p. 321. 

t Schultze. " Der Scheintod Neugeborenen," Jena, 1871, pp. 6, 130, 147. 

X Schultze, op. cit., p. 127. 

\ "Am. Jour. Obs.," vol. xi., p. 802. 



510 ASPHYXIA NEONATORUM. 

later. Poppel found that the mortality of asphyxiated children 
in the first eight days after delivery is seven times greater than 
that of the unasphyxiated, and the mortality in the first week is 
in direct ratio to the duration and gravity of the symptoms at- 
tending the asphyxia. 

Treatment. — There are three indications for treatment,* viz: 
1. The child must be brought as rapidly as possible into a posi- 
tion to inspire atmospheric air. 2. The inspired foreign bodies 
must be removed from the air passages. 3. If the irritability of 
the medulla oblongata has been so weakened that no spontaneous 
inspirations, or only very feeble ones, are made, the normal con- 
dition of the central organ must be restored by artificial respi- 
ration. 

With respect to the first indication, no special directions are 
necessary, as the various modes of accelerating labor have re- 
ceived attention in other chapters. 

Mucus may be cleared from the throat by inverting the body, 
and passing the finger over the base of the tongue. For the pur- 
pose of removing mucus and fluids from the trachea and bron- 
chi, a soft catheter or tracheal tube should be slipped along the 
finger, and passed into the trachea, and suction by the mouth in- 
stituted and maintained as long as the tube fills. The mere 
presence of the tube will often excite respiration, but, should it 
fail, artificial respiration through the tube should be begun and 
maintained as long as necessary, or until all possibility of sav- 
ing the child has disappeared. 

In those simple cases where the child does not at once 
breathe, yet the heart and cord pulsate normally, a slap on the 
nates, simple elevation and lowering of the arms a few times, or 
the sudden application of heat or cold, will suffice to arouse the 
respiratory forces. 

The third indication alluded to may be accomplished by sev- 
eral methods. 

Sylvester's Method.— This consists in drawing forward the 
tongue, placing the infant on its back, and extending the arms 
above its head. This movement, which favors inspiration, is 
then followed by bringing the arms down to the sides, and com- 

* SCHBOEDER. op. dt.. p. 323. 



METHODS OF ARTIFICIAL RESPIRATION. 511 

pressing the thorax. These motions should be repeated about 
twenty-five times per minute. 

Marshall Hall's Method.— Place the child in a prone posi- 
tion, which favors expiration by compressing the chest. Then 
roll it on to its right side, which expands the thorax. These 
movements should be repeated a like number of times per min- 
ute as the foregoing. Neither of the preceding methods, as 
they appear to us, are well suited to the revival of an asphyxi- 
ated child, unless it should chance still to be sensitive to im- 
pressions. 

Schroeder's Method. — In this method inspiration and expi- 
ration are produced by alternately extending and flexing the 
spine in the following way: "The thorax can be dilated by 
supporting the back, the head, pelvis and arms being allowed to 
fall backwards; a powerful expiration is then obtained by bend- 
ing the child over the abdominal surface, thereby compressing 
the thorax." 

Schultze's Method. — It consists of the following manipula- 
tions: The child is so held between the legs of the accoucheur 
that the thumbs are placed upon the anterior surface of the 
thorax, the index finger in the axilla, and the other fingers along 
the back; the face of the child is turned away from the ac- 
coucheur. The child, thus grasped, is then swung upwards, so 
that the lower end of the trunk turns over toward the accouch- 
eur; and by bending the trunk in the region of *the lumbar ver- 
tebrae, the thorax is greatly compressed. By such passive ex- 
piratory movements the inspired liquids pass abundantly- out of 
the respiratory openings. A very powerful inspiration is then 
produced by extending the body of the child by swinging it 
backwards, so as to return it to its previous position. In this 
way expiration and inspiration are repeated untiyiiey become 
spontaneous. 

Howard's Method. — The child is laid on its back on the 
operator's left hand, the ball of the thumb supporting the back 
and extending the spine, thereby causing the shoulders to droop 
and the head to bend downward and backward. The buttocks 
and thighs are supported by the operator's fingers. The thorax 
is then grasped by the right hand, and by means of it, while the 



512 INDUCTION OF PREMATURE LABOR. 

left affords counter- pressure, the chest is compressed, and al- 
lowed to expand, at the rate of from seven to ten times per 
minute. 

After respiration has been established, the child must be 
watched until it has gained its natural red color, moves the 
limbs actively, and cries with a loud voice. 






CHAPTEE XYI1I. 

Obstetric Operations. 

The Induction of Premature Labor. — This operation may 
be called for in the interest of either mother or child, or on be- 
half of both. It may be employed with benefit in three varie- 
ties of cases: 1. In moderate degrees of pelvic deformity. 2. 
In habitual death of the foetus. 3. In diseases which imperil 
the life of the woman. 

Methods of Operating. 
There are a number of methods by means of which uterine 
contractions can be provoked, but they differ considerably in 
their applicability to particular cases, their general efficiency 
and their safety. Those which we shall mention are among the 
most approved. 

Rupture of the Membranes.— This is the oldest method, 
and is most easily performed. It is not well suited to cases in 
which speedy delivery is sought, as there is sometimes great de- 
lay after rupture, before the uterus takes on expulsive action. 
Still, we may regard the method as certain^ It is not always an 
easy matter to rupture the membranes when the cervix uteri lies 
high, and the os is pretty well closed. It is best done we be- 
lieve by the careful use of either a rather stiff sound or a probe- 
pointed catheter. It is desirable to have the liquor amnii escape 
slowly, and to secure such a result, Hopkins has recommended 
tapping the membranes with a sound at a distance from the os 



METHODS OF OPERATING. - 513 

internum. Puncture of the membranes is regarded as one of 
the safest modes of inducing premature labor. 

Artificial Dilatation of the Cervix Uteri.— Dilatation of 
the cervix is usually begun by means of tents, but extensive 
expansion can hardly be accomplished with them. There are 
objections to most of the rubber dilators offered for sale, chiefly 
on account of their danger of rupture, and irregular expansion. 
Barnes' bags are excellent for cases to which they are suited, but 
considerable dilatation is required as a preliminary to their use, 
since the smallest cannot be employed until expansion is great 
enough to admit two fingers. Such means, if persisted in for a 
time, are most effective; but they must be used with the utmost 
caution. Tents should not be frequently repeated, or additional 
ones crowded into place with force, for fear of denuding the 
cervical canal of its epithelium; nor should Barnes' dilators be 
permitted to keep up a constant and powerful strain for a great 
length of time. If the cervix is in a condition of rigidity, great 
force, even though hydrostatic, will result in harm. 

Intra-Uterine Injections. — For this purpose a gum elastic 
catheter is introduced between the membranes and uterine walls, 
for a distance of about two or three inches, or further, and 
through this a few ounces of water, at about the temperature of 
the body, is injected. If the first injection fails to excite uterine 
action, it should be followed by another. The use of this method 
has several times been attended with sudden death, attributed to 
entrance of air into the uterine veins, to shock, and to rupture 
of the uterus, and hence has not been very popular. 

Introduction of a Catheter or Bougie. — In multipara this 
operation is performed without great difficulty; but in prirnip- 
ara a certain amount of preliminary dilatation will often be 
found necessary, which may be accomplished with a single tent 
well introduced. When ready to operate the woman should be 
placed upon the bed or table, with her hips at its edge. The 
point of the instrument is then directed by a finger into the 
cervical canal, and after it passes the internal os, it should be 
turned to one side so as not to puncture the membranes. No 
amount of force should be used to urge it onward, and when it 
cannot be further introduced, it may be left. It is desirable to 



514 INDUCTION OF PKEMATUEE LABOR. 

leave only an inch or two of the extremity protruding, as it 
would otherwise extend through the vulva. 

This operation is tolerably safe, is easily performed, and is 
generally quite effective. Uterine action is excited within a few 
hours. It may be adopted as an adjunct to some other means, as, 
for example, Kiwisch's douche, a description of which here fol- 
lows. 

Kiwisch's Douche. — This process consists in directing a con- 
tinuous stream of warm water against the os uteri by means of a 
tube connected with a fountain syringe, or an apparatus which 
operates on the same principle. Some prefer the alternate use 
of hot and cold water. The injection should be repeated once 
or twice a day, for ten or fifteen minutes at a time, until uterine 
contractions are excited. Twelve are said to be about the 
average number required. In urgent cases they may be em- 
ployed every three or four hours; but the method is not well 
adapted to cases in which rapid delivery is desirable. 

This method has by some been changed, measures being taken 
to prevent escape of the injected fluid from the vagina, with a 
view to effecting anatomical detachment of the membranes from 
the uterine walls; but the innovation has proved a dangerous 
one. The operation as originally recommended is comparatively 
free from risk, but is often extremely slow in its action. At one 
time the method was an extremely popular one, but it has now 
fallen into comparative disuse, except as a means of effecting 
preliminary dilatation of the os. 

Introduction of Foreign Bodies into the Yagina. — Braun's 
colpeurynter, Gariel's air pessary, and the ordinary tampon, have 
been used as means of inducing premature labor. The effect is 
excitation of reflex uterine action, and more or less mechanical 
dilatation of the os uteri, with separation of the membranes. 
These measures, while tolerably safe and certain when carefully 
employed, are not highly regarded by the most skillful physi- 
cians. The distension of the vagina should not be ^excessive, 
and must not be long-continued or the vaginal tissues will be 
liable to suffer. 

The Induction of Abortion. — The physician is certainly 
justifiable in inducing abortion whenever the operation offers the 
best chance of saving the woman's life, but only after due con- 



CONDITIONS CALLING FOR VERSIONS. 515 

sideration, and when his conviction of its advisability has been 
strengthened by counsel. The main conditions which unite to 
demand the operation are: 1. Incarceration of the prolapsed 
or retroflexed uterus, when the dislocation cannot be reduced; 
and 2. Diseases of pregnancy which greatly endanger life, and 
which have refused submission to all carefully chosen remedies. 

We believe it is equally justifiable to induce abortion in those 
cases of extreme pelvic deformity, or of pelvic tumors, which are 
quite sure to make the performance of abdominal section a ne- 
cessity, should pregnancy be permitted to go on. 

The operation is performed by introducing a sound, and sweep- 
ing it about in the uterine cavity; by introducing a soft cathe- 
ter; or by the dilatation of the cervix with sponge tents. 



CHAPTEE XIX. 

Turning. 

Turning consists in the performance of a manoeuvre by means 
of which one presenting part is exchanged for another, as when 
the head in a case of placenta prsevia is converted into a footling 
presentation, or the shoulder in a transverse case is changed into 
a cephalic presentation. Two general varieties of turning are 
practiced, viz: the cephalic and the podalic t Among the an- 
cients, cephalic version only, was practiced, under the mistaken 
idea that labor could not well be terminated in any other than 
head presentation. The form of version now most popular, and 
which in general is more easily and safely performed, is the po- 
dalic, which consists in bringing down the feet when some other 
part presents, and thereby converting the case into a footling 
presentation. 

Conditions Calling for the Operation.— Turning is called 
for in a variety of conditions wherein speedy delivery is requir- 
ed, and especially those in which the necessity has developed or 
been disclosed during the earlier part of the first stage of labor. 



516 TUKNING. 

Among the conditions demanding this sort of interference we 
may mention placenta praevia, transverse presentations, certain 
degrees of pelvic contraction, prolapse of the funis, sudden 
death of the mother, and some cases of uterine rupture. 

Conditions Favorable to the Operation. — In order that any 
form of version may be easily and safely performed, the os and 
cervix uteri must be either dilated, or freely dilatable, and the 
membranes either unruptured, or but recently broken. 

Cephalic Yersion. — This form of version is but rarely prac- 
ticed, chiefly for the reasons that it requires the concurrence of 
so many favorable conditions, and that the circumstances which 
necessitate version are usually of so pressing a character as to 
require the speedy termination of labor, a thing not always 
easily accomplished in connection with cephalic version. Still, 
in some favorable cases it is the preferable mode of version. 

The operation can occasionally be practiced by external ma- 
nipulation alone, but it usually requires the combined internal 
and external method. 

To perform the external manoeuvre, the woman should be 
placed on her back with her hips raised above the level of her 
head and shoulders, so as to place the long uterine axis more 
nearly in coincidence with a horizontal plane, and the knees ele- 
vated. The abdomen must be exposed or covered only with 
some thin material. By abdominal palpation the two poles of 
the long foetal diameter, namely, the pelvic and cephalic, are to 
be located, and the hands placed upon them. Operating then 
between pains, an attempt is made to push upward the pelvic 
extremity, and to bring the head into the pelvic brim. During 
uterine action the only effort should be to maintain the advance 
obtained. The manoeuvre of external version may sometimes be 
aided by turning the woman upon the side toward which the 
head lies, but the position is unfavorable for manipulation. 

After bringing the head into the brim, it may be retained by 
suitable pressure made with the hand, but better still, if the os 
is dilated, by the application of the forceps; or the membranes 
may be ruptured and the liquor amnii permitted to escape. 
What answers a very good purpose, are pads applied to the 
sides of the abdomen, along the line of the foetal prominence, 
and held in place by a well-adjusted binder. 



PODALIC VERSION. 517 

By the combined method, that is, by the simultaneous use of 
both external and internal manipulation, cephalic version is 
more easily performed. The method described and practiced 
by Braxton Hicks is probably the preferable one. He prefers 
the lateral decubitus, and uses the left hand when the patient is 
on the left side, and the right hand when she lies on the right 
side. We quote him as follows:* "Introduce the left hand 
into the vagina as in podalic version; place the right hand on 
the outside of the abdomen in order to make out the position of 
the foetus and the direction of the head and feet. Should the 
shoulder, for instance, present, then push it, with one or two fin- 
gers on the top, in the direction of the feet. At the same time 
pressure by the outer hand should be exerted upon the cephalic 
end of the child. This will bring down the head close to the os; 
then let the head be received upon the tips of the inside fingers. 
The head will play like a ball between the hands, and can be 
placed in almost any part at will. * * * It is as well if the 
breech will not rise to the fundus readily after the head is fairly 
in the os, to withdraw the hand from the vagina and with it 
press up the breech from the exterior." 

Ansesthesia is neither necessary, nor specially desirable for 
the practice of version by the combined manipulation, and hence 
the woman can be made to assume a position, which, in some 
cases, will be found to contribute to the successful practice of 
the operation, namely, the knee-elbow position. 

Podalic Tersion.— "The reasons why podalic version so rap- 
idly displaced in public favor the ancient turning of the head," 
says Glison,f " seem to be chiefly on account of its facility of 
performance, and rapidity in the termination of labor, for it is 
often very difficult to seize, bring down and properly adjust, the 
round, slippery head, by the old method of introducing the hand 
into the womb. By the modern external and bi-polar modes, 
especially the latter, the difficulty and danger are so much less, 
that turning by the head, in transverse presentations particularly, 
will become more popular. But where haste is necessary, in 
the latter presentation, as well as in all others adapted to turn- 

* " Combined External and Internal Version," "Trans, of the Obstet Soc'y 
of London," vol. v, p. 230. 
f " Text-Book of Modern Midwifery," p. 510. 



518 



TUKNING. 



ing, podalic version, and that too, in the regular way of intro- 
ducing the hand into the womb, must be resorted to." 

The operation may be performed by external manipulation, 
by the combined method, or by the introduction of the hand 
and seizure of the feet. 

Wigand, to whom we are mainly indebted for the introduction 
of the external method, considered it suitable only fco transverse 
cases. It is practiced so like cephalic version by external manip- 
ulation, that it requires no special description. 

Fig. 221. 




First stage of the combined method. 

Position of the Patient. — In practicing podalic version in 
any manner, the position generally recommended by American 
obstetricians is the dorsal. The patient should be so placed 
that her nates lie near the edge of the bed, with her feet resting 
on chairs, as in forceps delivery. The abdomen ought to be un- 



PODALIC VERSION. 



519 



covered, or have over it only a sheet, a light chemise, or a night 
dress. The physician should stand between his patient's feet 
with his face toward her. 

The Combined External and Internal Method.— The posi- 
tion and presentation having been determined, and the bladder 
and rectum emptied, the operation is performed much as is that 
of cephalic version, the two poles of the foetal oval being pushed 

Fig. 222. 




Second stage of the combined method. 

in opposite directions. The whole hand is never introduced 
into the uterus, but it may be necessary to pass it into the va- 
gina, on account of the inability to reach and handle the pre- 
senting part. In some cases chloroform will be required. The 
pre-requisites for success are: Sufficient dilatation of the cer* 
vix to permit the introduction of two fingers; a certain degree of 
foetal mobility; and a clear comprehension of foetal position and 
presentation. After rupture of the membranes and escape of 



520 TUENING. 

the waters, the operation becomes difficult, or even imprac- 
ticable. 

Internal Podalic Yersion.— This form of version, which was 
first practiced by Ambrose Pare, consists in introducing the 
hand into the uterine cavity, seizing the feet and bringing them 

Fig. 223. 



Third stage of the combined method. 

through the os uteri and vulva, while the body is made to ro- 
tate on its transverse axis. Sufficient dilatation is required to 
admit the hand without force, and, save in those cases where the 
utmost haste is demanded, the bi-polar, or combined method, 
should first be tried. Internal podalic version while still the 
most popular mode of turning, is rapidly giving way to the 
other methods, and may even now be said to be preferable 
chiefly in extremely urgent cases, and in placenta prsevia, where 
the hemorrhage during other manipulation could not be kept 
under control. It is the only practicable form of version when 
the liquor amnii has been long drained off, and a certain 
amount of uterine retraction has taken place. 

After the preliminaries as regards diagnosis, position, the 
evacuation of the bladder and rectum have received attention, 



PODALIC VEKSION. 521 

the woman has been drawn to the edge of the bed, and placed 
under anaesthetic influence, the physician should take a posi- 
tion in front of his patient, with hand and bare forearm well lu- 
bricated, with the exception of the palm, and proceed gently to 
insinuate his hand, the fingers slowly separating and expanding 
the parts, until it finally lies within the uterine cavity. When 
practicable he should choose that hand, the palmar surface of 
which, as it passes, corresponds to the ventral surface of the 
foetus; but in transverse presentations this is a matter of com- 
paratively slight importance, as by turning the woman there is 
no possible direction within the pelvis or the womb in which 
either the right or the left hand may not be passed. If the 
physician is not ambidextrous, he should use his most efficient 
hand, without reference to the foetal position. 

In cephalic presentations the question of hands is one of more 
importance, and the weight of experience favors the use of that 
hand, the palmar surface of which corresponds to the ventral 
surface of the child; hence with the woman on her back, in first 
and fourth positions of the foetus, the left hand should be used, 
and in second and third positions, the right. 

After the hand passes the vulva, which it is enabled to do by 
firmly repressing the perineum, it should pause for a moment 
to examine more carefully the presentation and position. Then 
with the external hand upon the fundus uteri, the internal one 
should be most gently urged through the os and cervix uteri. 
If the membranes are now intact, it makes very little difference 
whether we tear them with the fingers and then push onward 
through them, or pass the hand between the membranes and 
uterine walls until it comes into proximity to the feet, and then 
effect the rupture. 

If uterine action is at all forcible, the hand must be extended 
and remain passive until the contraction passes away; but if the 
uterine efforts are feeble, and almost continuous, as they some- 
times are, slow, but resolute, progress may be insisted upon. 

Obstetricians are at variance respecting the question of seiz- 
ing one or both feet for the performance of version. The safe 
rule of practice is to grasp both feet or knees if they lie within 
convenient reach, especially if there is an urgent demand for 
delivery; but, if both limbs cannot be easily seized, the most ae- 



522 



TURNING. 



Fig. 224. 



cessible one ought to be brought down without unnecessary de- 
lay, and without subjecting the woman to the dangers of further 
search. If the demand for delivery is not a pressing one, and 
both feet are within reach, we believe it advisable to take but 
one, but to make ourselves sure that the one selected is the de- 
sirable one. There is a positive advantage derivable from bring- 
ing down but a single foot, or 
knee, since by leaving one 
still flexed upon the body, 
greater dilatation of the os 
uteri, the vagina, and the vul- 
va, is necessitated by the 
passage of the pelvic portion 
of the foetus, and the diffi- 
culties and dangers of head 
extraction are thereby di- 
minished. 

That there is a difference 
in desirability between the 
two legs, we are fully convinc- 
ed: and the preferable one is 
that which lies toward the ab- 
dominal parieties. The ad- 
vantage in seizing this is 
found in the greater facility 
with which the foetus rotates 
on its longitudinal axis, and 
so descends that the head en- 
gages the pelvis with the occi- 
Version in head presentation. put looking f orwar d. This 

advantage is clearly demonstrable on the manikin. Yet this 
is not a question of much practical importance. 

In cases of turning in pelvic contraction, when extraction is 
likely to be difficult, it is regarded by some as highly advisable 
to bring down both legs; but the practical advantage of doing 
so, even there, is not obvious, since the rejected leg becomes free 
before the shoulders pass the vulva, and the special difficulty is 
in connection with extraction of the head. 

Unless care is exercised, the elbow is liable to be mistaken for 




RUNNING NOOSE ON THE FOOT. 



523 



the knee, and the hand for the foot; but ordinary attention will 
prevent our falling into such an error. 

Fig. 225. 




Version in transverse presentation. 

While drawing down the foot, or feet, with the internal hand, 
an effort should be made to push upward the head with the 
external. Before relaxing our hold on the feet we should 
make sure of the version, as otherwise the foetus is liable to be 
restored to its original position. If the head refuses to ascend, 
a running noose of tape or other material which will not injure 

Fig. 226. 




Use of the running noose on the foot. 

the foetal tissues should be slipped around the foot, and traction 
made on it by one hand, while the fingers of the other are used 
within the os uteri to push the head upwards. 
In some difficult cases of turning, it is unwise to relax the 



524 



TURNING. 



hold of the foot for the purpose of putting a noose on it, as it is 
liable to pass beyond reach, and occasion much trouble. In 
that case the fillet may be noosed around the operator's arm, 
and gradually slipped upward, until it can be placed on the foe- 
tal foot. If the version cannot be completed with one foot, the 
other must be brought down. 

When, in transverse presentations, the arm descends into the 
vagina, it somewhat embarrasses version, but does not prevent 
it. In such cases it is a good plan to place a noose of tape about 
the wrist, which enables the operator to control the arm, both 
while his hand passes into the uterine cavity, and later, during 
extraction of the trunk. 

Completion of the Delivery. — When the desired change has 
been effected, the question arises whether labor should be at 

Fig. 227. 




Turning by the noose or fillet. 

once completed, or now left to the natural efforts. If there be 
no urgent demand for delivery, nature may be given a fair op- 
portunity; but the woman is already anaesthetized, and very 
likely the pains are in great measure arrested, so that it would 
seem most wise to proceed carefully and close the second stage 



THE FOKCEPS. 



525 



of labor, for doing which no special directions are here re- 
quired. 



CHAPTEK XX. 



The Forceps, 

The obstetrical forceps were designed and used by one Paul 
Chamberlen in the early part of the seventeenth century. In 
1647, Peter Chamberlen, in a little pamphlet published by him, 
speaks of a discovery made by his father, Paul Chamberlen, for 
saving the lives of children during labor. It, however, remain- 
ed a family secret, bringing its possessor immense gain, and did 
not become public until 1733, in which year Dr. Chapman, in a 
brief treatise on obstetrics, said that " the secret mentioned by 
Dr. Chamberlen was the use of forceps, now well-known to the 
principal men of the profession, both in town and country." In 
another edition of his work published two years subsequently, 
he gave a cut of the instrument, which was afterwards known as 
ChaDman's forceps. Since that day modifications have been re- 

Fig. 228. 




Chamberlen's Forceps, 
peatedly made, but, unfortunately, " to innovate is not always to 
improve," and we accordingly find that, save in one or two par- 
ticulars, the forceps of to-day are practically but little better 
than the original blades of the Chamberlens. 

The instrument, as at first designed, was for application to 



526 THE FORCEPS. 

f 

the head when lying in the pelvic cavity or at the outlet; though 
it was sometimes used at the brim. Since that time the forceps 
have in some forms been considerably augmented in length, 
with the design to provide an instrument capable of grasping 
the head at the pelvic brim, or even above, and the result is that 
we now have the long forceps and the short forceps. 

The Short Forceps. — The short forceps owe their brevity 
chiefly to the abbreviation or entire absence of the shank, and 
the shortness of the handle, the fenestrated portion of the in- 
strument not being materially less than the same part of the 
long forceps. The instrument is recommended mainly because 
of its easy portability, and the possibility, in some cases, of rob- 
bing the operation of forceps delivery in great measure of the 
formidable character which it is liable to present. It is claimed 
by some of their advocates that they may even be applied with- 
out the knowledge of the patient, a statement which seems 
scarcely credible. Most patterns of short forceps possess the 
cephalic curve, but not the pelvic curve, — these being peculiari- 
ties of construction shortly to be explained. 

The Long Forceps. — Since it has been found in practice that 
the long forceps may be applied, not only at the brim, and above 

Fig. 229. 




Davis' Forceps. 
it, but also in the pelvic cavity and at the outlet, — in short, that 
the long forceps answer almost equally well the purposes of the 
short, most of the instruments at present manufactured are of 
the long variety. 

Without commenting on the different patterns of forceps 
which we find in the instrument shops, we have become con- 
vinced from use of a considerable variety, that, while we cling 



THE LONG FORCEPS. 



527 



to instruments of a certain form, our preferences may proceed 
largely from frequent use, for there are few of the more promi- 
nent varieties which are really poor. The features to be sought, 

Fig. 230. 




Comstock's Forceps. 
are handles of moderate length; blades as light as are compati- 
ble with great strength; a cephalic curve sufficiently acute to 

Fig. 231. 




Budd's Forceps. 

afford a hold on the head which will not slip, even when taken 
over its long diameter; and a pelvic curve acute enough to ena- 

Fig. 232. 




Simpson's Forceps. 

ble the point of the blades to easily clear the sacral promontory, 
without excessive depression of the shanks against the per- 
ineum. 



I 



528 



THE FORCEPS. 



The Salient Features of the Instrument.— The blade of 
the instrument is constructed with a fenestra varying in width, 
and slightly so in general shape. This part of the instrument 



Fig. 233. 




Elliot's Forceps, 
requires to be strongly made, and none but the best quality of 
steel should be used in its construction. In order to give the 
blade a firm hold upon the head, it is provided with what is 

Fig. 234. 




Hodge's Forceps, 
termed the cephalic curve. We believe with Dr. Landis * that, 
" with a proper head-curve the tips of the blades will approxi- 
mate to such an extent, when the instrument is applied, that 

Fro. 235. 




Hale's Long Forceps, 
traction upon the blades brings their distal end upon the farther 
* " How to Use the Forceps," p. 95. 



SALIENT FEATURES OF THE INSTRUMENT. 



529 



end of the head, so as to not only securely hold it, but also to 
push it onwards. When forceps are said to slip during their 
use, one of two things is certain; either the head-curve of the 

Fig. 236. 




Tedder's Forceps, 
instrument is insufficient, or the blades have not been properly 
applied." He should have added, perhaps, " or traction is not 
made in the right direction." The pelvic curve is a feature of 

Fig. 237. 




Leavitt's Forceps, 
the utmost importance. By means of it the forceps are more 
easily applied, and extraction is more easily effected. There is 
one disadvantage associated with it, namely, our inability to 






530 THE FOKCEPS. 

make traction in the line of the pelvic axis. To overcome this, 
several expedients have been resorted to, the most prominent of 
which is exemplified in Tarnier's axis traction forceps, a cut of 
which we herewith present. 

Fig. 238. 




Tarnier's Forceps. 

The forceps are provided with a variety of handles. Hodge's 
and Comstock's, for example, have slim metal handles which ter- 
minate in blunt hooks; but most other patterns have wooden 
handles, provided at their distal extremities with shoulders or 
rings, upon or within which, the fingers may rest in making 
traction. The wooden handles are far preferable. 

Designations of the Blades. — In English text-books the 
blades are spoken of as the male and female, and the upper and 
lower. The latter designation has a double meaning, growing 
out of the position of the woman. In English practice the ob- 
stetric position is on the left side, and the lower blade when 
locked with its mate is not only beneath or behind the other, but 
it is also in the lower side of the pelvis when applied. In Amer- 
ica the common, and most convenient designations, are the right 
and left. The right blade is naturally handled with the right 
hand, and usually goes more or less into the right side of the 
pelvis; while the left blade is most conveniently handled with 
the left hand, and commonly goes more or less into the left side 
of the pelvis. 

Action of the Forceps. — The forceps are primarily and es- 
sentially tractors.* Their action is also, in a modified sense, 

* LuSK. *' Science and Art, of Midwifery," p. 339. 



ACTION OF THE FOBCEPS. 



531 



that of levers and compressors. A certain amount of lateral 
oscillation gives greater power to the instrument, and if made 
without relaxation of traction efforts, and within moderate lim- 
its, it can do no harm. The antero-posterior, or "pump handle" 
movement, should never be executed. 

Fig. 239. 




The forceps at the brim, by the pelvic mode. 



The degree of compression exercised by the forceps should be 
in direct ratio to the force of the traction; the chief aim being 



532 



THE FORCEPS. 



to retain a firm embrace of the head. When made slowly and in- 
termittingly, the head of the foetus will bear a great degree of 
compression. 

Modes of Application.— There are two modes of forceps ap- 
plication, namely, the cephalic or oblique, and the pelvic or di- 
rect. The former is used chiefly in the pelvic cavity, and at the 
outlet; while the latter is employed more especially at the pelvic 
brim and above it. The cephalic mode is always preferable, so 
far as foetal interests are concerned; but out of deference to ma- 
ternal interests it is not always advisable. 

Fig. 240. 




Forceps in the pelvic cavity, by the cephalic mode. 
The Pelvic Application.— In adopting this we do not study 




CONDITIONS DEMANDING THE FORCEPS. 533 

the cranial position and materially vary our application to suit 
it, but we pass the blades into the sides of the pelvis. Since 
this mode of application is used mainly in the high operations, 
and inasmuch as the foetal head usually occupies an oblique pel- 
vic diameter, the blades generally embrace the head over the 
brow, on one side, and the mastoid process on the other. This 
form of application is adopted because of the difficulty and dan- 
ger associated with the blades on the sides of the head. 

The Cephalic Application. — In this we study the position cf 
the f cetal head, and vary our application to suit it, the endeavor 
always being to apply the blades to the sides of the head. 

Conditions Calling for the Forceps. — " It would be an un- 
profitable undertaking," remarks Lusk, "to enumerate all the 
conditions which render forceps advisable. The indications for 
their use may be summed up in two general propositions. The 
forceps is applicable — 1. In cases where the ordinary forces oper- 
ative during labor are insufficient to overcome the obstacles to 
delivery. 2. In cases where speedy delivery is demanded in the 
interest of either mother or child. 

" Both these propositions are, however, subject to the limita- 
tion that, in the selection of the mode of delivery, choice should 
be made specially with reference to the maternal safety. For- 
tunately, in the great proportion of cases the interests of both 
mother and child are identical." 

The Preliminaries. — When the operation has been decided 
upon, it is advisable in most cases to administer an anaesthetic 
before in any way changing the patient's position. An anaesthetic 
is not absolutely required, and some women object to it, prefer- 
ring to suffer the necessary pain rather than take what they re- 
gard as an unnecessary risk. If the head lies in the cavity, or 
at the outlet, the pain attendant on forceps delivery is not suffi- 
cient to make the anaesthetic a necessity, and it may be omitted. 
We would advise against partial anaesthesia; either let it be en- 
tirely omitted, or carried to the extent of complete narcosis. Its 
administration may be begun by the operator, and subsequently 
entrusted to an intelligent nurse, or other attendant, provided no 
skilled assistant is at hand. 

It is assumed that the bowels and bladder have been recently 



534: THE FORCEPS. 

evacuated. If they have not, a good enema should be adminis- 
tered before beginning the anaesthesia, and the catheter intro- 
duced after the woman has been prepared for the operation. 

The forceps should be thoroughly clean, and for a short time 
before their use, should stand in a warm, antiseptic solution. 
Meanwhile the membranes, if intact, should be ruptured, and 
the woman turned so as to lie on her back across the bed, with 
the hips well to the edge. 

The Application. — We have found but little practical differ- 
ence in the application of the forceps, between a high and a low 
head, except in the adoption of the pelvic mode in one case, and 
the cephalic in the other. A proper adjustment of the forceps 
in one case is almost as difficult as in the other. When the 
head lies low, it is within easy reach, but the difficulty is in- 
creased by the adoption of the cephalic mode of application. 
When the head lies high, it is not so easily reached, but by the 
pelvic mode the forceps are made to go easily into place. The 
only exception to be made is in the instances of marked pelvic 
deformity, and a partially dilated os uteri. 

The patient's feet now resting on the edge of the bed, or 
placed in chairs and there held by assistants, the operator as- 
sumes his place directly in front of the woman, and, having lu- 
bricated the blades, takes the left one in his left hand, holding 
it between the thumb and fingers much as he would a pen, and 
introduces it a short distance, while he uses two or more fingers 
of the opposite hand, resting against the presenting surface, as 
a guide to the point of the instrument. The blade at this stage 
will form almost a right angle with the maternal body, the han- 
dle looking slightly to the woman's right. Now, remembering 
the double curve of the blade it is made to take a spiral sweep, 
the handle passing over the patient's right thigh, until, in a high 
application, the shank presses firmly on the perineum. A com- 
mon mistake is that of attempting to carry the blade directly to 
its place without first passing its point into the sacral hollow, 
and then to its proper position by a broad spiral sweep. In ap- 
plying the forceps to the sides of the head, the sweep of one 
blade will be but slight, while that of the other will be unusu- 
ally great, as will be seen from a study of figure 238. 

The application of the second blade is similarly made, the in- 



THE APPLICATION. 



535 



strument being held in the right hand, and guided by the left. 
In giving it the necessary sweep, the handle is made to pass over 
the woman's left thigh. 

Fig. 241. 




Introduction of the first blade. 

Both blades now being in situ, no difficulty will be experienced 
in making them lock. If the adjustment is not accurate, they 
should be gently manipulated, but no amount of force should be 
employed to make' them lock. 

Traction. — The forceps once on, and locked, it next becomes 
the operator's duty to effect delivery, and to do so safely re- 
quires some knowledge concerning traction. The handles of the 
instrument should be held in a convenient way, and so as not to 
exert too great compression of the foetal head. If the pains con- 
tinue, traction efforts should be made coincidently with them, if 
absent, traction should take their place. But we usually find 
that as soon as we begin to draw on the forceps, the uterus is 
excited to action, and the vis afronte is aided by the visa tergo. 



536 



THE FOBCEPS. 



Fig. 242. 



The force employed should at first be moderate, and afterward 
stronger; but so long as the resistance is offered mainly by soft 
structures, as, for example, an incompletely dilated cervix, or 
vulva, the utmost caution must be exercised. In no case should 
much traction be applied at the vulva, for fear of lacerating the 
perineum. 

The direction of traction will be 
indicated pretty well by the direc- 
tion of the handles in the inter- 
vals between pains. In high op- 
erations it is at first downwards? 
and possibly a little backwards; 
but as the head descends it should 
be turned more and more for- 
wards, until the handles at the fi- 
nal passage come to form almost a 
right angle with the long axis of 
the woman's body. 

Removal of the Forceps.— 

When the head is embraced over 
the poles of its bi-parietal diam- 
eter, there is no necessity for re- 
moval of the forceps until after 
complete delivery of the head; 
but when, from adoption of the 
pelvic mode of application, the 
head is held over its occipito-f ront- 
al, or over an oblique diameter, 
in performing rotation the head will carry the blades into such 
positions as to endanger the perineum posteriorly, and the ves- 
tibule anteriorly, and we regard careful removal of the in- 
strument a wise precaution. Before displacing the forceps the 
head should be made to nearly reach the crowning stage, and 
then, after removal, it can easily be delivered by Fasbender's 
manoeuvre, described in another chapter, which consists in plac- 
ing the index and middle fingers over the occiput, and then run- 
ning the thumb as deeply into the rectum as possible; having 
done which, we may at will, with, or without, the assistance of 
the natural forces, press the head through the vulva. 




Showing how the head is usu 
ally seized in the " cephalic appli 
cation." 



THE EOECEPS IN OCCIPITO-POSTERIOR POSITIONS. 537 

Forceps in Occipito-Posterior Positions.— We are told that 
" so long as the occiput looks to the rear, it is the rule of mid- 
wifery practice to refrain from the use of forceps, which, of 
necessity, prevent" forward rotation taking place." * Moreover, 
it is added: "As attempts to rotate the occiput around to the 
symphysis by instrumental means are rarely successful, it is ad- 
visable under such circumstances to apply the forceps directly 
to the sides of the child's head, and to imitate during delivery 
the mechanism of labor in occipito-posterior positions. If the 
sagittal suture occupies an oblique diameter, the forceps should 
be applied in the opposite oblique diameter. As the head de- 
scends, the occiput should be turned into the hollow of the sa- 
crum." "We are convinced from experience that it is possible to 
do much better than this. 

Accordingly, when there exists a demand for the forceps above 
the brim, with the occiput looking more or less backward, we 
believe it to be the operator's duty to endeavor carefully to ro- 
tate the head, so that its long diameter will coincide with the 
transverse of the pelvis, before applying the instrument. By 
virtue of such a change he is enabled, with $he forceps in the 
sides of the pelvis, to grasp the head in its long axis, and ef- 
fectually prevent a backward movement of the occiput, and, if 
requisite, to enforce proper rotation. On the contrary, when 
the instrument is so applied without the observance of the pre- 
caution mentioned, the head is seized in one of its oblique di- 
ameters, as has already been shown, and even slight compression 
disposes the occiput to rotate into the hollow of the sacrum. 

The change is so easily accomplished in suitable cases that 
explicit directions are not required. The head, as felt in the 
hypogastrium, should be pressed backwards, whilst the occiput 
should be drawn forwards with the fingers of the other hand. 
Having effected an alteration, the acquired position should be 
maintained by firm and equable pressure in the supra-pubic 
space, until the forceps have been adjusted to the head. In de- 
fault of so doing, it is very liable to revert to the original posi- 
tion. 

Observation teaches that the head, when clearly above the 
brim, is not always freely movable, and then all prudent efforts 

* Vide Lusk, loc. cit., p. 353. 



538 THE FORCEPS. 

to change its position will be utterly unavailing. To such cases, 
including as well those in which the head lies in the superior 
strait, a different treatment is applicable. If the occiput is 
turned more or less forward, or directly to one side, the physi- 
cian has but to pass the blades according to the usual directions 
for the pelvic application; but if it is more or less backward, 
then, instead of putting the blades squarely in the sides of the 
pelvis, let him place them on the face and occiput, — a thing, we 
confess, not always easily done, — and thereby embrace the head 
over the poles of its occipito-frontal diameter. 

When once the instrument is fairly adjusted, if the head is 
found to be unfixed in the brim, it may be gently raised, and 
carefully rotated from one oblique diameter into the other, but 
the operator should beware of violence. If such a movement is 
not practicable, the head should be drawn, with usual precau- 
tions, to the pelvic floor, and then, if the natural efforts are inef- 
fectual, the desirable evolution can easily be enforced. 

The forceps are occasionally required in the situations de- 
scribed, but much oftener after the head has descended into the 
pelvic cavity. With respect to the mode of treatment best suit- 
ed to the latter class of cases, a few years appear to have wrought 
a change in the opinion and practice of many excellent accouch- 
eurs. The older authorities teach, and we believe with much 
force, — that, when the head lies in the pelvic cavity, the forceps 
should be applied in the diameter opposite to that occupied by 
the long cranial diameter, so that they will rest on the parietal 
eminences. Some later writers, to whom allusion was made, 
appear to prefer the pelvic mode of application even there, in 
adopting which the instrument will sometimes go to the sides of 
the head, but usually not. These methods may be equally well 
suited to the class of cases most commonly met; but for third 
and fourth positions of the vertex, we call attention to a third, 
and, in many instances, a preferable mode. It would be super- 
fluous to reiterate the disadvantages, in these positions, of the 
blades squarely in the sides of the pelvis. In pursuance of an- 
other mode they may be placed to the sides of the head, but, 
when so adjusted, their curve is thrown towards the face, in- 
stead of the occiput, and, when rotation takes place, they must 
either be removed, or suffer inversion. To be brief, then, the 



THE FORCEPS IN FACE PRESENTATIONS, 539 

recommendations made in connection with the head at the 
brim maybe adopted here, and, avoiding unnecessary repetitions, 
we may say that, save in conspicuously unsuitable cases, the 
blades should go over the face and occiput, and not be removed 
until the head is ready to escape the vulva. 

The Forceps in Face Presentations. — Application of the 
forceps to the face when it lies high in the pelvis is not permis- 
sible unless the chin is turned somewhat forward, and the blades 
can be applied to the sides of the head. An application over 
the fronto-mental diameter of the face should never be made, 
and therefore, when the mental pole is not directed more or less 
forward, the head lying at the brim, or above it, our operative 
resources, in case delivery is called for, are conversion of the 
face into vertex presentation, version, and craniotomy. 

In mento-lateral, or posterior, positions, with the head in the 
cavity or at the outlet, we believe the forceps may be used if 
necessary, and forward rotation of the chin effected. In fine, if 
the case seriously threatens to persist with the chin to the sa- 
crum, we believe it to be a conservative operation for both 
mother and child, to apply the forceps, and, operating with ex- 
treme care, attempt to bring the part forward. The author has 
so done in one case, and that without harm. The instrument 
in that instance will require a double application, unless we chance 
to have a pair of straight forceps. In the first application, the 
pelvic curve of the instrument should look toward the forehead, 
and after rotation has been effected as far as the transverse di- 
ameter, it should be removed, and reapplied with the curve di- 
rected toward the chin. Rotation is then to be slowly perform- 
ed, always cooperating with the pains, and maintaining, at the 
same time, firm extension. 

In mento-anterior positions no unusual danger attends the 
forceps, provided they are always applied to the lateral surfaces 
of the head. 

If the physician is thoroughly versed in the mechanism of la- 
bor, and comprehends the sphere and action of the forceps, he 
will be able to make the instrument perform faithful service for 
him in most trying emergencies. 

Use of the Forceps on the Breech.— Breech presentations 

are generally aided, when aid appears to be required, by instru- 



540 THE FORCEPS. 

ments constructed for the purpose, namely, the blunt hook and 
the fillet. By means of these, properly applied to the flexure of 
the thighs, considerable force may be exerted and delivery effect- 
ed. But when we come to compare them, in all their essential 
features, with the ordinary obstetric forceps, and reflect upon 
the respective uses of each, we discover that the latter instru- 
ment is much better suited to a safe and easy delivery of the 
presenting head, than are the former instruments to a safe and 
easy delivery of the presenting breech. The fillet requires great 
effort and consummate skill for its application to a breech not 
within easy reach of the fingers ; and the blunt hook, while easi- 
ly applied, is extremely liable to do serious injury to the foetal 
tissues. 

The ordinary forceps, though designed for the head, may be 
effectively and safely applied to the breech. Forceps of a pecu- 
liar pattern have been constructed for this purpose; but the com- 
mon forceps, (the short straight forceps being preferable, we be- 
lieve, ) when adjusted to the sides of the foetal pelvis, that is to 
say, over the poles of the transverse pelvic diameter, are equally 
harmless and efficacious. 

The author has made this use of the forceps in iave cases, and 
has been well satisfied with the results obtained. 

From study, experience and reflection, we have deduced the 
following conclusions: 

1. That the forceps may generally be used in breech presen- 
tations to better advantage than any other instrument, and with 
less danger than the blunt hook. 

2. As a preliminary to the operation, it is essential that the 
position be unmistakably recognized. 

3. The blades, when on, should embrace the pelvis over the 
poles of its transverse diameter, as a much better hold is thereby 
acquired, and dangerous pressure with the points of the instru- 
ment is thereby obviated. 

The Forceps to the After-coming Head. — This is an oper- 
ation but seldom required, and it has been sufficiently described 
in another chapter. 



MINOR OBSTETRIC INSTRUMENTS AND OPERATIONS. 



541 



CHAPTEE XXI. 

Minor Obstetric Instruments and Operations. 

The Tectis. — The vectis, or lever, was devised by Eoonhuysen 
of Holland, about the time that the Chamberlens began to use 
the forceps in Great Britain. Eoonhuysen handed down the 
secret to his sons and others, and it was eventually purchased by 
Drs. Visscher and Van den Poll, for 5,000 livres, and imparted to 
the profession. The instrument was long popular, but it has 
now largely fallen into disuse, not because of its intrinsic worth- 
les*sness, but because it is so far eclipsed by the forceps. By 
some prominent authors it is not even mentioned. 

The vectis greatly resembles a single blade of the straight 
forceps. Several patterns of the instrument are in use, two of 
which are herewith given. 

Fig. 243. 



r 



Folding Vectis. 

Its Uses. — We believe that this instrument may be used to 
advantage in a number of unfavorable conditions, and, since its 
employment does not necessitate the formalities of the usual in- 
strumental delivery, less objection will be offered, and eases at- 
tended with few outward indications of abnormality may be 
greatly facilitated, which would otherwise be permitted to drag 
their slow length along. Furthermore, the skill necessary to 







542 MINOR OBSTETRIC INSTRUMENTS AND OPERATIONS. 

safely employ it, and the difficulties attending its use are not so 
great as we find in connection with the forceps, and hence the 
ordinary practitioner will be more inclined to avail himself of 
its aid. 

Fig. 244. 



n 



Ryerson's Vectis. 

In many instances the forceps are said to be demanded when 
the difficulty and delay in labor has arisen from extension of the 
foetal head. The yectis is peculiarly well suited to just suT3h 
cases, and when, by its simple leverage and traction, the exten- 
sion is overcome, labor goes on apace. In occipito-posterior 
positions, when rotation is not disposed to take place in the de- 
sirable direction, the vectis is capable of affording much assist- 
ance, and by it the occiput may be brought forward. This is 
true also of the chin in those most trying mento-posterior posi- 
tions of face presentation. 

The instrument acts as both lever and tractor. In exercising 
its leverage powers we should be extremely careful not to make 
any part of the pelvic structures its fulcrum. Without a ful- 
crum its leverage action cannot be displayed, but it must be 
supplied by one hand of the operator, while the other acts upon 
the power arm of the instrument. A certain amount of traction 
may be exerted by the instrument as it is pressed firmly against 
the fcetal head, but it is awkward and generally inefficient. 
G reater traction force can be applied when the fingers of the 
operator are made to take the place of the second blade. 

The Blunt Hook. — This, like the vectis, is an ancient instru- 
ment, formerly much used for extracting the foetus in breech 



PASSING THE CATHETER. 



presentation, and occasionally in cephalic presentation attended 
with delay in delivery of the shoulders. It is intended to be 
hooked into the flexure of the thigh, or into the axilla, but it 
is so apt to injure the foetal tissues that, for the extraction of a 
living foetus, it has fallen largely into disuse. 



Fig. 245. 




Taylor's Blunt Hook. 

Hypodermic Injections.— Though directions concerning the 
use of the hypodermic syringe do not properly belong to a trea- 
tise on midwifery, yet, since the employment of hypodermic 
medication, and especially the sub-cutaneous injection of ergot is 
herein recommended for certain conditions, and furthermore, 
inasmuch as some of our homoeopathic remedies act much better 
when so employed, we offer the following hints: 

1. The best sites for puncture are the back of the arm, on a 
line with the insertion of the deltoid muscle, and the abdominal 
tissues near the umbilicus. 

2. The needle should be passed deeply into the tissues, so that 
its point will be at least half an inch below the integument. 

3. The fluid should be slowly injected. 

Catheterism. — This may be deemed scarcely worthy the title 
of an obstetric operation, and still in many cases its difficulties 
are such as to try the skill of even those of extensive experience. 
The variety of catheters which is best suited to obstetrical prac- 
tice in general is the soft rubber, both because of its facility of 
introduction and freedom from danger. Still, the gum elastic 
and silver catheters generally answer the purpose. 

Mode of Performance. — The catheter may be passed with a 
single hand, or with both. When both hands are used, the oper- 
ator may stand by his patient's right side, and pass the fingers 
of his left hand between her thighs, as she lies with the limbs 
flexed, and locate the meatus, while with the opposite hand the 
point of the instrument is made to engage. Or he may stand 
between the woman's feet, as she lies on her back, and pass the 



544 



MINOR OBSTETRIC INSTRUMENTS AND OPERATIONS. 



index finger of the left hand into the vagina but a short distance, 
with its palmar surface looking upwards. Now if the finger is 
made to lie flatly against the anterior vaginal wall, it will rest on 
the urethra, while the meatus will lie close to the margin of the 
vagina, just within the vestibule. By remembering these points, 
introduction of the instrument will be greatly facilitated. With 

Fig. 246. 




Soft Rubber Catheter. 
the soft rubber catheter now held in the other hand, between the 
thumb and forefinger, the point of it can easily be made to catch 
the meatus. If these instructions are followed, there is no occa- 
sion to make any effort to locate the meatus with the point of 
the finger, and thus render the effort more embarrassing and 
difficult. 

When a single hand is used, the catheter should be held as 
shown in Fig. 247, while the middle finger is made to rest just 

Fro. 247. 




Manner of holding the catheter, 
within the vaginal orifice, against its anterior margin, and the 
paeatus will be found directly under the point of the catheter. 



TRANSFUSION. . 545 

It should be remembered that the meatus lies directly at the 
crown of the pubic arch, and as the middle finger of the single 
hand, or the index finger in the double hand operation, are 
pressed against the urethra as it lies in the anterior vaginal wall, 
they will easily feel the pubic arch, and thereby secure further 
aid to introduction. Nor should it be forgotten that, when 
the woman lies on her back, the catheter, in introduction, should 
be given a direction somewhat downwards and backwards. 

To perform catheterism skillfully requires considerable prac- 
tice, but, above all, thorough acquaintance with the anatomy of 
the external generative organs, and the details of the operation. 
To expose the parts, and locate the meatus with the eye, is a 
most indelicate and unnecessary proceeding. 

The Transfusion of Blood.— A few words should be written 
on the subject of transfusion of blood, an operation which, 
though attended with many difficulties and discouragements, 
and one which, through lack of marked success, has not often 
been employed, we cannot pass over in silence. 

The operation dates back several hundred years, but it did not 
come into prominent professional notice until Dr. Blundell pub- 
lished his work entitled, " Researches, Physiological and Patho- 
logical," in 1824. 

The design of the operation is to supply to a circulation which 
has been greatly depleted, blood from either a lower animal, 
generally a sheep, or another human being who is willing to 
make the necessary sacrifice. 

The great practical difficulty in transfusion has always been 
the coagulation of the blood shortly after it leaves the body. 
Blood in which fibrination has begun is not only useless for in- 
jection, but highly dangerous, as small coagula may enter the 
circulation and cause embolism. To obviate this difficulty, three 
different methods have been adopted, viz. : 1. Immediate trans- 
fusion from arm to arm, without permitting the blood to be ox- 
posed to the atmosphere. 2. Adding to the blood certain chem- 
ical reagents, which have the power to prevent coagulation. <">. 
Removal of the fibrine, and injection of only the liquor san- 
guinis and blood corpuscles. 

The Immediate Method. — For the purpose of immediate 
transfusion Dr. Aveling has invented an apparatus which works 



546 



MINOR OBSTETRIC INSTRUMENTS AND OPERATIONS. 



much on the principle of a bulb syringe, without valves. One 
extremity is connected with a canula inserted into the vein of 
the person supplying the blood, and the other into a vein of the 
patient, and by operating it much like a syringe, and making 
the fingers serve for valves, the blood is transfused. Dr. Fryer 
has designed an instrument which in some respects, is an im- 

Fig. 248. 




Fryer's instrument for immediate transfusion. 

provement on that of Dr. Aveling, and a cut of it is herein pre- 
sented. 

Chemical Prevention of Coagulation. — Dr. Braxton Hicks, 
who has been one of the strongest advocates of this method, 
proposes to make a solution of three ounces of fresh phosphate 
of soda in a pint of water, about six ounces of which are to be 
added to the full quantity of blood to be injected. This prevents 
coagulation, and the injection of a certain amount of it has been 
attended with some benefit; but the method does not recommend 
itself to the indorsement of a rational mind. 

Defibrination of the Blood. — This is done by whipping it, 
and then removing the fibrine by straining. The operation need 
not be a hurried one, and the rapidity of the injection is a mat- 
ter easily controlled. It has been successfully employed in a 
large number of cases, appears to be attended with little danger, 
and is most easily performed. It is the operation which com- 
mends itself to the general practitioner, and may yet, in his 
hands, prove a blessing to mankind. Blood thus transfused has 
been proved to become provided with fibrine soon after entering 



TRANSFUSION. 



547 



the circulation. The first injection need not exceed six or eight 

Fig. 249. 




Allen's Transfuser. 

ounces, as, if necessary, it can be repeated. 



548 MINOR OBSTETEIC INSTRUMENTS AND OPERATIONS. 

Allen's Instrument for Immediate Transfusion.— An in- 
strument for immediate transfusion has been invented by Mr. 
E. E. Allen, which works on an entirely new principle, and which, 
in experiments, has shown itself far superior to any other. By 
means of it, coagulation of the blood as it passes from arm to 
arm is prevented, and the velocity of the current is regulated at 
will. We are at present performing some experiments with the 
instrument, and will be glad to answer any personal inquiries 
with reference to it. 

Mr. Allen has also invented what he terms the " skin cup," 
which obviates the introduction of a canula into the vein of the 
donor, and which, by simple mechanism, prevents the possible 
entrance of air. 

Fig. 250. 




The - Skin Cup." 

Transfusion of Milk.— The intra-venous injection of fresh 
milk, under conditions similar to those demanding the transfu- 
sion of blood, was first practiced by Dr. Hodder, of Toronto. It 
has since been experimented with by Dr. Thomas and Dr. 
Brown-Sequard, and its efficacy has received their endorsement. 
The latter found, in his experiments on the lower animals, 
that the milk was as efficacious as either fresh or defibrinated 
blood, and its globules could not be found one half hour subse- 
quently to the injection. Transfusion of milk certainly prom- 
ises most excellent results. For a single injection eight ounces 
are usually sufficient. The milk should be warm, perfectly 
fresh, and of good quality. To insure its freedom from foreign 
matters, it should be passed through a fine piece of muslin. It 
may be carried into the circulation by passing into a vein a small 



CRANIOTOMY. 549 

canula, to which is connected a small tube in relation with a ves- 
sel containing the milk, which by its own weight is siphoned 
through the apparatus. 
Mode of Exposing the Veins Selected for Transfusion.— 

This part of the operation is a most delicate one, rendered un- 
usually so by the collapsed state of the vessels sought. The best 
way to expose them is to pinch up a fold of skin at the bend of 
the elbow, and transfix it with the knife, when upon opening the 
wound, the veins will be found lying at the bottom of it. By 
passing a probe under the vein it may be secured, and through 
a small nick made in it, the canula can be passed. The appa- 
ratus having been previously filled with either blood or milk, to 
prevent the introduction of air, the injection may be begun with 
the greatest caution. 



CHAPTEE XXII. 

Operations Involving Destruction of the Foetus. 

Craniotomy.— Under the head of craniotomy are generally 
classed all the operations, the performance of which involve mu- 
tilation of the head of the child. It is one of the oldest^ oper- 
ations of midwifery, evidently having been practiced in the 
time of Hippocrates. 

Its Sphere.— Craniotomy is employed in those cases of diffi- 
cult labor wherein neither the forceps nor turning can be effectu- 
ally adopted. It is also occasionally had recourse to (though 
not always wisely) in certain contingent accidents which happen 
during parturition, as in some cases of accidental and unavoida- 
ble hemorrhage, in some cases of convulsions, in certain cases of 
uterine rupture, and in those cases of protracted labor in which, 
from the neglect or ignorance of the physician in attendance, the 
pelvic organs and tissues are brought into such a state from 
pressure, that delivery by other means would be extremely has- 



550 



CRANIOTOMY. 



ardous to the life of the woman. It is also employed in difficult 
labor, when there is positive evidence of foetal death. 

Frequency of Employment. — From the statistics which fol- 
low it will be seen that the frequency with which this operation 
is had recourse to varies greatly among private practitioners, 
hospital physicians, and the obstetricians of various countries. 
Dr. Collins reports that, during his mastership at the Dublin 
Lying-in Hospital, 16,414 women were delivered, during which 
time craniotomy was performed seventy-nine times. Dr. Joseph 
Clarke reports that, in 10,387 case of labor, craniotomy had 
been performed forty-nine times. According to Dr. Churchill's 
statistics, British practitioners resort to craniotomy once in 219 
cases; the French, once in 1,205^ cases; the Germans, once in 
l,944i 

Instruments Employed. 

The Perforator. — There are many patterns of perforators, 
but those illustrated in the accompanying cuts are among the 
best. The instrument ought to be well made, straight and 
strong. It is the first instrument used in performing crani- 
otomy, and, when properly constructed, can be employed with- 
out danger to the maternal tissues. In cases of emergency, a 
bistoury, or even a pocket-knife may be used, if the head is in 
the pelvic cavity. 

The possibility of mistakes being made in connection with 

Fig. 251. 




Thomas' Perforator. 

perforation will be seen when we say that the sacral promontory 
has been pierced under the supposition that it was the foetal 
head. 

The Crotchet.— The crotchet is a hook, made of highly-tem- 
pered steel, possessing a sharp point, the design of which is 
fixation in some portion of the base of the skull, generally on 



THE PERFORATOR. 



551 



its internal surface, by means of which traction may be made. 
For many years it was the only instrument used as an ex- 
tractor after perforation. It is powerful in the hands of a 
skillful operator, but a highly dangerous instrument when em- 
ployed by the ignorant or inexperienced. All forms of the in- 

Fig. 252. 




Blot's Perforator. 

strument are open to the serious objection of being liable to 
slip, and wound either the maternal soft parts, or the hand of 
the operator which should always be used as guard. It has 
gone almost into disuse. 

Fig. 253. 




Blunt Hook and Crotchet. 

Craniotomy Forceps.— This instrument is used for both ex- 
tractive and destructive purposes. It is intended to lay hold of 

Fig. 254. 




Thomas' Craniotomy Forceps. 

the skull, one blade passing within the cranium, and the other 
on the outside. With the hold thus obtained, forcible traction 
can be made, and, save in cases of considerable pelvic contrac- 
tion, extraction effected. 

In some instances, however, it becomes necessary after perfo- 
ration, not only to break up and wash out the brain substance, 



552 



CRANIOTOMY. 



but also by these forceps to remove the cranial bones in fra$ 

Fig. 255. 




Use of tlie craniotomy forceps. 

ments, before the bulk of the head is sufficiently reduced to 
enable it to be drawn through the pelyic canal. 
• The Cranioclast. — The cranioclast may be regarded as a 
pair of large craniotomy forceps, which admirably answer the 
purpose of delivery in many cases. The instrument designed 
by Sir James Simpson is that most commonly employed in 
Great Britain. In America the cranioclast is not often used. 
It consists of two blades fastened by a button joint. The ex- 
tremities are shaped like a duck-bill, and are sufficiently curved 
to give a firm hold of the head. The upper blade is provided 
with a deep groove into which the other sinks. 

The female blade is applied outside the head, and the male 



THE CEPHALOTEIBE. 



553 



blade is passed through the opening made by the perforator, 
and then the cranial bones are all separately crushed by the 
forcible grasp of the instrument. This having been done, the 
cranioclast is made to take a final hold, when it is turned upon 
Fig. 256. ^ s ^ on S ax ^ s several times, thereby 

twisting the scalp, and expelling more 
of its contents, after which extrac- 
tion is easily effected. 

The Cephalotrilbe.— In 1829, Bau- 
delocque proposed a cephalotribe for 
crushing the cranium in labors ob- 
structed by pelvic distortion. It was 
used in France and on the Continent, 
but was not adopted in England and 
America till a much later period. 
The cephalotribe is a large and power- 
ful instrument, intended to grasp the 
head, crush it, and then to extract it. 
The instrument, as commonly con- 
structed, resembles a large and strong 
pair of obstetrical forceps. It is suit- 
ed to pelves distorted by rickets, rath- 
er than malacosteon, and hence should 
receive special favor from American 
obstetricians. No rule can be given 
as to the amount of pelvic space re- 
quired for its safe em'ployment. 

Perforation is generally recommend- 
ed to be first performed, though Bau- 
delocque regarded the preservation of 
the integrity of the scalp as one of the 
advantages of his method. The blades 
of the instrument are to be applied in 
the same manner as the blades of 
the long forceps in a high operation. Like the ordinary for- 
ceps, the instrument may be applied through a partially di- 
lated os uteri, when circumstances seem to demand the opera- 
tion under such conditions. In order that the base of the skull 




Simpson's Cranioclast. 



554 



CRANIOTOMY. 






may be readied, the blades should be deeply inserted. When 
the blades are in situ, compression is gradually applied by means 
of the screw. As the diameters of the head are diminished in 
one direction they are increased in another, but, except in in- 
stances of excessive pelvic contraction, this is a matter of no 
great importance. 

Fig. 257. 




Lusk's Cephalotribe. 
If necessary the instrument may be carefully removed and ap- 
plied so as to compress the head in its opposite diameter. Pajot 
claimed to be able to deliver through pelves contracted below 
two and one-half inches by thus crushing the head in different 
directions. 

Fig. 258. 




Fo&tal head crushed by the cephalotribe. 

Before beginning extraction, the aperture made by the per- 
forator should be examined to see that there are no projecting 
speculse of bone. 

Comparative Merits of Cephalotripsy and Cranioclasm. — 

The relative merits of the cephalotribe and the cranioclast^ 
as instruments with which to bring a mutilated child through 
a distorted pelvis, are not fully settled, but there appears 
to be no doubt that the cranioclast enables us to extend the 



CRANIOTOMY AND CESAREAN SECTION. 555 

limits of safe delivery far beyond what would be admissible 
with the cephalotribe, as by means of it we may, after partial or 
complete removal of the flat bones of the cranium, tilt the chin 
downwards, and draw the base of the head edgewise through 
the conjugate diameter of the pelvis. 

Comparative Merits of Craniotomy and the Cesarean Sec- 
tion. — Early Cesarean section appears to furnish as good ground 
for hope, in cases of extreme deformity, as craniotomy. Dr. 
Harris* publishes a table of seventeen American cases in which 
the operation was performed during, or at the close of the first 
day of labor, which shows a mortality of a little less than thirty 
per cent. 

Of 103 cases of craniotomy coming under the observation of 
Bokitansky, forty-one, or about forty per cent., terminated fa- 
tally. 

Embryotomy, when Yersion Cannot be Effected. — The 

second class of destructive operations is that wherein mutilation 
of other parts of the body than the head is performed. Embryot- 
omy is most likely to be required in neglected cases of trans- 
verse presentation in which turning cannot be effected. Our 
choice at such a time lies between decapitation and evisceration. 

Decapitation. — This operation consists in severing the head 
from the body, having done which, the latter can easily be with- 
drawn by means of the arm, and subsequently the severed part 
extracted. This is the operation to be preferred if the neck can 
be reached without much difficulty. Many instruments have 
been devised for effecting the purpose, but what is known as 
Ramsbotham's decapitating hook has met with much favor. To 
use the instrument it is slipped over the neck, and the part 
divided by a sawing motion. The most difficult part of the op- 
eration consists in getting the hook over the neck. To obviate 
this difficulty, some have recommended the use of a spring, with 
a string, which may be more easily passed. By the same means 
the chain of an ecraseur may be drawn over, and the head thus 
severed. A stiff male catheter may also be employed instead o\' 
a spring. The decapitating hook, though a good instrument, 
cannot be made serviceable for any other purpose, and as it is 

* "American Journal Obs." Feb.. 1872. 



556 EMBKYOTOMY. 

so rarely required, few feel like providing themselves with it. 
The ecraseur, however, is a surgical instrument of relatively- 
frequent use, and with one of them every practitioner is expected 

Fig. 259. 





Decapitating Hook. 

to be provided. It requires gentle manipulation to avoid 
wounding the maternal tissues, and the greatest care must be 
exercised. Some prefer a pair of strong scissors, with which 
they pierce the neck, and then divide the spinal column. 

Extraction of the Body and Subsequent Delivery of the 

Head. — There is rarely much difficulty experienced in getting 
away the body. The arm is usually prolapsed, and by traction 
on it extraction is effected. The head, still in utero, may be held 
at the brim, while the cephalotribe is applied, which is generally 
regarded as the preferable instrument for delivery. Collapse 
of the head takes place by escape of the brain through the 
vertebral canal. The obstetrical forceps can sometimes be 
used with success. In other cases the head may be perforated, 
and then the craniotomy forceps employed for extraction pur- 
poses, one blade being introduced within the perforation, and 
seizing upon the cranial bones, while the other is made to lie ex- 
ternally and exert counter pressure to secure the hold. 

Evisceration. — Our choice should rest upon this operation 
only when decapitation cannot be practiced. In executing it 
the thorax is perforated at its most accessible point, and the 
opening made as large as possible, in order that the viscera may 
be removed, and the foetal bulk thus decreased. The perforator 
is swept about within the cavities, and the organs are thus broken 
up as much as possible, preparatory to their removal in frag- 
ments. The thoracic and abdominal cavities thus being opened, 
and to a great extent evacuated, the foetus should be made to 
perform an evolution, by means of which its pelvic extremity de- 
scends, and delivery is thus effected. This movement may be 



EVISCERATION. 557 

facilitated by division of the spinal column between the vertebrae 
by means of a stont pair of scissors, or even a knife, carefully 
used, and then by traction with the crotchet, fastened on the 
pelvic bones internally. 

Fig. 260. 




Mode of using the decapitating hook. 

A number of cases have been recorded wherein neither deoap- 



558 CESAREAN SECTION. 

itation nor evisceration could be successfully performed, and the 
operator was driven to the performance of gastro-hysterotomy. 



CHAPTEE XXIII. 

The Cesarean Operation.—Porro's Operation— 
Laparo-elytrotomy—Symphysotomy. 

Gastro-hysterotomy, or the Cesarean section, consists of an 
incision made through the abdominal and uterine walls for the 
purpose of extracting the child. 

The post-mortem operation was performed at a very remote 
period of antiquity; but hysterotomy on a living woman was 
first practiced probably not more than four centuries ago. In 
the sixteenth century it become so very frequent that a Domin- 
ican friar, Scipia Merunia, was led to remark that it was as com- 
mon in France as blood-letting in Italy. 

Cesarean Operation on the Living Woman. — This opera- 
tion, regarded as one of the most formidable in the whole range 
of surgery, is now practiced whenever the natural passages 
through the pelvis are so narrow, or so obstructed, that delivery 
cannot otherwise be accomplished. The actual amount of con- 
traction which calls for the operation is not agreed upon by ob- 
stetricians, and there is no doubt that other elements beside 
mere contraction exercise a decided influence over particular 
cases in determining the necessity for the operation; as, for ex- 
ample, the character of the instruments employed, and the skill 
of the operator. The necessity for hysterotomy has been ob- 
viated by some operators where the pelvic conjugate was only 
one and one-half inches ; and in the practice of others, it has been 
demanded and performed, even in modern times, in pelves meas- 
uring two and one-half inches in their antero-posterior diameter. 

Causes of Death after the Operation. — The causes of 
death after the operation, are hemorrhage, peritonitis, metritis, 



RESULTS OF THE OPERATION. 



559 



shock, septicaemia, and exhaustion — being substantially the same 
as those following ovariotomy. 

Results of the Operation. — Caesarean section has not been 
attended with such encouraging results in English as in Ameri- 
can practice. Up to January, 1881, there had been performed 
in Great Britain and Ireland 134 Caesarean sections, the result 
being successful in eighteen per cent, of them. The better re- 
sults obtained in American practice are shown in the following 
table, prepared by Dr, R. P. Harris.* 

TABLE OF CESAREAN CASES OPERATED UPON IN THE DIFFER- 
ENT STATES, SHOWING VERY MARKED DIFFERENCES IN 

SUCCESS. 





oi 


Women. 


Children. 


Sa 


u W 


White Women. 


Black Women. 


States. 


O 




w 


Q 


&5 ' 
> 


O 





Q 


Q 




< 

u 


W 
P 


> 

3 


P 


3 
< 




S3 

CQU 


w 
P 


> 


P 


J 


Louisiana .... 


20 


5 


15 


11 


9 


1 


19 




1 


5 


14 


New York .... 


14 


11 


3 


10 


5 


12 


2 


10 


2 


1 


1 


Alabama 


10 


7 


3 


8 


2 


3 


7 


1 


2 


6 


1 


Ohio 


10 
10 


3 
6 


7 
4 


A 

5 


6 

5 


10 

7 


3 


3 
4 


7 
3 


2 




Pennsylvania. 


i 


Virginia 


9 


7 


2 


6 


3 


3 


6 


2 


1 


5 


l 


Indiana 


6 


4 


2 


4 


2 


5 


1 


4 


1 




l 


Mississippi .. . 


6 


4 


2 


1 


5 


1 


5 


1 




3 


2 


Georgia 


5 


b 




4 


? 


1 


4 


1 




4 




Michigan 


3 


2 


i 


1 


2 


3 




2 


i 






Missouri 


3 


3 




3 




3 




3 








Arkansas 


2 


1 


i 




2 




2 






i 


1 


California 


2 


1 


1 


2 




2 




1 


i 






Connecticut.. . 


2 


1 


1 


1 


1 




2 






i 


1 


Illinois 


2 




2 


1 


1 


2 






2 






Iowa. 


2 
2 


1 
1 


1 
1 


1 
2 


1 


2 
1 


i 


i 


1 
1 


i 




Kentucky 


i 


N. Carolina. . . 


2 




2 


1 


i 


1 


i 




1 




"Wisconsin 


2 


2 




1 


l 


2 




2 








Maine 


1 


1 






l 


1 




1 








Maryland. 


1 


1 




i 






i 






l 


i 


Massachusetts. 


1 




i 




i 




i 








New Jersey . . 


1 


i 






i 


i 




1 








N. Hampshire. 


1 


l 






l 


i 




1 






i 


S. Carolina. . . 


1 




i 




l 




l 








Tennessee .... 


1 


i 






l 


i 




1 








Not stated 


1 


l 




i 




i 




1 








Total 


120 


70 


50 


68 


52 


64 


56 


40 


24 


30 


26 



Cases reported in medical journals, 65 ; recovered, 35=53 11-13 per cent, o( 

*cies obtained through correspondence, 55; recovered, 15=27 3-11 per oo.u. 
•f cures. 

* " Am. Jour. Obs." Vol. xiv., p. 347. 



560 



CESAREAN SECTION. 



Dwarfs from 3 ft. to 4 ft. 8 in. high, 24 ; recovered, 7. Whites, 5 ; blacks, 2. 

White dwarfs, 17; black dwarfs, 7. Shortest white recovered, 3 ft. 11 J in^ 
black, 3 ft, 9 in. Uterine sutures used in 20 cases, of which 7 recovered. Sil- 
ver wire was used in 10, saving 5. 

The Operation. — The following directions concerning the 
performance of this very important operation we quote from 
Dr. Thomas Badford,* who has performed hysterotomy quite a 
number of times, and who from general surgical and obstet- 
rical experience is qualified to offer sound advice. 

FiCx. 261. 




The Cesarean Operation. 

General Considerations. — "The operation ought not to bo 
made one of display. There should only be a very few persons 
present, and the greatest quietude should be afforded to the pa- 
tient. Every cause likely in any way to create unpleasant emo- 
tional feeling should be most carefully avoided. These rules 
were strictly observed in the two successful cases in which I 
was engaged. It is of the first importance, to adopt all such 
measures as will prepare the patient to undergo this operation, 
by improving the general health. 



* " Observations on the Cesarean Section, Craniotomy, and other Obstetric 
Operations," p. 24. London, 1880. 



PRELIMINARIES. 561 

Preliminaries.—" The bowels should be emptied by a large 
quantity of warm water thrown into the rectum and colon, by 
an enema-apparatus with a long flexible tube (like the one used 
to enter the stomach), so that its extremity can reach beyond 
the great projection of the sacrum. 

" The bladder must also be emptied by a catheter, equal in 
length to that used for the male. This organ is forced down- 
wards and forwards, and lies under the deflected uterus, where- 
by its cervix is lengthened and compressed upon the pubes. 
This altered position of the bladder is particularly to be ob- 
served during the latter month of pregnancy, in cases of pelvic 
distortion from mollities ossium. 

Examinations. — " Frequent examinations per vaginam have 
been already shown to be extremely injurious ; so that this prac- 
tice should not be allowed. In an exploration made to ascer- 
tain the measurement of a distorted pelvis, the obstetrician is 
compelled to pass his hand completely, and as far as possible 
into the vagina. Anxious to ascertain the state of the os uteri, 
the presentation of the infant, and the exact available space in 
the pelvis, he prolongs the operation, and often repeats it. And 
when consultations are numerous (as is too common) in these 
cases, serious mischief is inflicted on the pelvic organs and tis- 
sue. By one effectual examination, every necessary informa- 
tion can be obtained. The interest of the patient is best secur- 
ed by having only a limited number, (say two persons) in con- 
sultation. 

" The operation should be performed on the bed; so that the 
patient may be kept as quiet as possible afterwards. In some 
of the cases in which the woman was removed to a table, some 
untoward circumstance happened. 

" The temperature of the room should be regulated, and a 
genial warmth of the atmosphere maintained. 

Form of the Uterus. — "The uterus projects more or less 
forwards; and when the pelvic distortion is caused by mollities 
ossium, this organ assumes the retort shape. Its projection is 
so great that its normal anterior surf ace rests upon the thighs of 
the patient when she sits, so that the fundus necessarily stands 
most foremost. Before the incision is made, it is of the utmost 



562 C^SAKEAN SECTION. 

consequence to raise the deflected uterus up ; or else the fundal 
tissue, which abounds with large anastomosing vessels, must un- 
avoidably be divided. Neglect of this caution has, no doubt, led 
to the hemorrhage which happened in some of the cases. A di- 
vision of the structure of the upper part of the fundus of the 
uterus must certainly interfere with the regular or efficient con- 
traction of this organ, and thereby produce a gapping character 
of the wound. 

Advisability of Operating Early. — " When we contemplate 
the mischievous effects of protracted labor, and review the un- 
favorable condition in which most of the patients have been 
brought by unwisely procrastinating the operation, we must at 
once be convinced how important it is to perform it early. The 
sooner the better it is had recourse to after it is determined 
upon, either as one of election or one of necessity. 

" ^hen labor is rendered difficult by great distortion of the 
pelvis, or by large exostoses, or by large tumors in its cavity, 
some of those natural organic changes are not to be found 
which would otherwise guide us, and enable us to judge of its com- 
mencement and progress. To wait, then, in such cases as these 
for the dilatation of the os uteri is not only a great mistake, but 
also a very great evil; for, in most of them, this part of the 
uterus cannot be touched, and, in general, very little dilatation 
of it does or can take place. 

"The dangers of delay, on expectant grounds like these, 
which so frequently happened in the registered cases, ought to 
guard us against waiting for those indications which cannot pos- 
sibly be discovered, and induce us to operate early. As soon as 
the labor is established, and before or immediately after the 
membranes are ruptured is the most favorable time to proceed. 
Great advantage accrues from adopting this plan; for the length 
of the uterine incision would relatively diminish in size, equal 
to the diminution which takes place by the contraction of the 
uterus. Another great advantage arising from this course is, 
that the danger of protraction would altogether be avoided. It 
is a well-known fact that little risk comparatively occurs before 
the waters are discharged. 

Placental Complications. — " Before the incision is made the 
location of the placenta should, if possible, be ascertained, in 



THE INCISIONS. 563 

order to avoid its being wounded. In the seventy- seven cases it 
is reported as follows: In twenty-nine it was connected to the 
fore part of the uterus; of this number, in two it was placed 
towards the fundus ; in thirteen it was cut open. In ten cases 
it was adherent on or towards the back part of the uterus. In 
thirty-one cases the position of it is not alluded to, and, there- 
fore, it is to be presumed it was posteriorly placed. In five 
cases it occupied the fundus; in one case it was found near the 
left Fallopian tube, and in one case it was attached (placenta 
praevia) over the os uteri. 

" This minute inquiry as to the precise fixture of the placenta 
has not been made merely for the purpose of suggesting rules 
of caution, which ought to be observed before making the in- 
cision; but, also, of proving that this organ has not a definite 
position assigned to it. 

" It is, then, of the greatest importance to make the incision 
so as to avoid, if possible, cutting upon the placenta, as consid- 
erable danger may accrue from so doing. 

" The stethoscope will nearly always enable us to avoid these 
hazards. By it we derive positive information of the infant's 
life by hearing distinctly the pulsations of its heart, and it af- 
fords us negative evidence of the infant's death when no cardiac 
sounds are perceived through it." * * * * " If it be dead, 
no great risk will be incurred if the placenta be divided, as the 
vascular function of this organ will then, doubtless, have ceased. 

The Incisions. — " The position and direction of the external 
incision has varied. In fifty-seven cases it has been made lon- 
gitudinally ; in eleven of which number it was made on the right 
side, in twenty-four cases it was made on the left side, and in 
twenty-two cases it was made in the centre of the abdomen. In 
two cases it had a transverse direction on the right side. In 
one it was made obliquely on the right side. In seventeen cases 
the situation and direction of the wound is not recorded. 

" I prefer the wound to be longitudinal, and on the left side.* 
"There are no tissues concerned in the operation which re- 
quire very slow or nice dissection; therefore, unnecessary tedi- 

* Most obstetric surgeons prefer to make the incision as much as possible in 
the line of the linea alba; and if there is much bleeding the vessels are to be 
secured before opening the peritoneal cavity. 



564 CESAREAN SECTION. 

ousness should be especially avoided. If the uterus be slowly- 
incised, the stimulus of the knife instantaneously throws this 
organ in violent and irregular contraction, which separates the 
placenta and entails mischief on both the mother and the infant. 
Every precaution having been taken, we ought to strictly ob- 
serve the motto, ' ciio et tuio.' The incision should be made 
on the body of the uterus, because this portion of the organ is 
eminently contractile, and ought to extend well towards the fun- 
dus, but not into it. It ought not, however, to be carried too far 
down into the cervix uteri, because this part possesses dilatable 
properties which are unfavorable to a diminution in the size of 
the wound. 

Extraction of the Child. — "When the uterine incision is 
completed, there should be no delay in withdrawing the infant. 
"When it lies in its usual natural position, with the head over the 
brim of the pelvis, then the obstetrician should seize its legs 
with the right hand, and pass his left cautiously and quickly 
down so as to embrace the face on one side, or the hind part of 
the head. By this mode a double power could be effectually 
exerted; one of traction by the legs, the other by raising the 
head upwards." 

"If the breech offer at the incised uterine opening, the practi- 
tioner should seize it with his right hand and withdraw it, and 
at the same time use his left hand as above mentioned. If the 
head lie in proximity with the incision, then it ought first to be 
brought forth, and, at the same time, he should pass one hand 
cautiously forward along its body so as fairly to embrace the 
breech, and act with both his hands as recommended above. 
These precautionary rules are suggested to prevent the grasping 
seizure of the neck or the hips of the infant, as the case may be, 
during its removal. One or two writers have urged that the 
head of the infant should be always first extracted, on the 
grounds of being safer for it, but a conditional practice, accord- 
ing to its position in the uterus, is by far the best." 

" The head is most generally situated in the lower segment of 
the womb, and, therefore, at some distance from the centre of 
the incision. In order to bring it fairly to the opening, it would 
produce a great strain on, if not laceration of, the contracted 
uterine tissue, and create nearly a doubling of the child upon 



CLOSURE OF THE WOUNDS. 565 

itself before it could be extracted. And as expedition is re- 
quired, it would be found that the bulk of the head was not very 
readily grasped with sufficient firmness so as to ensure its speedy 
withdrawal. Time would be lost, and impediments added. The 
placenta, with the membranes, should be also quickly extracted. 

Prevention of Intestinal Protrusion.—" Protrusion of the 
intestines is yery apt to occur during the operation; this becomes 
very troublesome to the operator and distressing to the patient, 
and a considerable time is consumed in order to replace them. 
This accident not only predisposes to remote mischief, but it 
immediately tends to depress the vital powers of the woman. 
She feels faint and has a sense of sinking. Every care should, 
therefore, be taken by the assistants to repress and retain these 
viscera under the instruments by an extended application of both 
hands on each side of the incision." 

Closure of the Wounds.—" The advisability of closing the 
uterine wound by sutures," says Playfair,* "is a mooted point. 
The balance of evidence is entirely in favor of this practice, as 
tending to prevent the escape of the lochia into the peritoneal 
cavity. Interrupted sutures of silver wire or carbolized gut 
may be used, and cut short ;f or, as successfully practiced by 
Spencer Wells, a continuous silk suture may be applied, one end 
being passed through the os into the vagina, by which it is sub- 
sequently withdrawn. Before closing the uterine wound one or 
two fingers should be passed through the cervix, to insure its 
being patulous. A free escape of the lochia in this direction is 
of great consequence, and Winckel even advises the placing of 
a strip of lint, soaked in oil, in the os, so as to keep up a free 
exit for the discharge. 

"A point of great importance/and not sufficiently insisted on, 
is the advisability of not closing the abdominal wound until we 
are thoroughly satisfied that hemorrhage is completely stopped. 
since any^escape of blood into the peritoneum would very ma- 
terially lessen the chances of recovery. In a successful case 
reported by Dr. Newman, J the wound was not closed for nearly 

* " System of Midwifery," Am. Ed., 1880, p. 518. 

f The catgut suture has proved a faikre. It does not hold. 

$"Obstet. Trans.," vol. viii. 



566 OESAKEAN SECTION. 

an hour. Before doing so, all blood and discharges should be 
carefully removed from the peritoneal cavity, by clean, soft 
sponges dipped in warm water. The abdominal wound should 
be closed from above downwards, by hair lip pins, wire or silk 
sutures, which should be inserted at a distance of an inch from 
each other, and passed entirely through the abdominal walls and 
the peritoneum, at some little distance from the edges of the 
incision, so as to bring the two surfaces of the peritoneum into 
contact. By this means we insure the closure of the peritoneal 
cavity, the opposed surfaces adhering with great rapidity. The 
surface of the wound is then covered with pads of folded lint, 
kept in position by long strips of adhesive plaster, and the whole 
covered with a soft flannel belt." 

Antiseptic Precautions. — The operator cannot be too care- 
ful to use every precaution to prevent septic infection. The at- 
mosphere of the room must not become contaminated from the 
presence of anybody or anything that may convey the poison. 
The hands of the operators, their instruments and sponges, 
must all be above suspicion, and be subjected to thorough dis- 
infection before coming in contact with the patient. 

After- Care of the Patient. — The care of the patient after 
the operation differs in no essentials from that prescribed for 
women upon whom ovariotomy has been performed. 

POST-MOETEM C/ESAEEAN SECTION. 

The Cesarean operation will also be advisable in those cases 
wherein women meet with sudden death during pregnancy or 
labor, and a living child is left in utero. There can be no rea- 
sonable doubt that many children have thus been saved who 
would otherwise have perished. The percentage of success in 
these cases, however, is not so large as we might be led to ex- 
pect. Schwartz * collected 107 cases, out of which number not 
one child was saved. These, however, do not truly represent 
the chances which the operation gives the child, for Duerf has 
tabulated fifty-five cases, out of which number forty resulted in 
the delivery of living children. The lapse of time between the 
maternal death and foetal extraction was as follows: "Between 

* Monat. f. Geburt., suppl. vol., 1861, p. 121. 

f " Post-mortem Delivery," Am. Jour. Obs.. Jan., 1879. 






POST-MOETEM CESAREAN SECTION. 567 

1 and 5 minutes, including 'immediately,' and 'in a few min- 
utes,' there were 21 cases; between 5 and 10 minutes, none; be- 
tween 10 and 15 minutes, 13 cases; between 15 and 23 minutes, 

2 cases; after 1 hour, 2 cases; and after 2 hours, 2 cases." The 
last two cases did not long survive. Both these tables of cases 
may probably be justly regarded as extremes, and therefore a 
fair estimate of success may be made only by drawing the mean 
between them. * 

The Want of Success Attending the Operation.— "The 

reason that the want of success has been so great," says Play- 
fair, f "is doubtless the delay that must necessarily occur before 
the operation is resorted to, for independently of the fact that 
the practitioner is seldom at hand at the moment of death, the 
very time necessary to assure ourselves that life is actually ex- 
tinct will generally be sufficient to cause the death of the foetus. 
Considering the intimate relations between the mother and 
child, we can scarcely expect vitality to remain in the latter 
more than a quarter, or, at the outside, half an hour, after it has 
ceased in the former. The recorded instances in which a living 
child was extracted ten, twelve, or even forty hours after death, 
were most probably cases in which the mother fell into a pro- 
longed trance or swoon, during the continuance of which the 
child must have been removed. A few authenticated cases, how- 
ever, are known in which there can be no reasonable doubt that 
the operation was performed successfully several hours after 
the mother was actually dead." 

the Operation. — The desirability of operating with the ut- 
most dispatch in such cases, has already been shown, but, since 
the maternal death was in some instances only apparent, the 
operation should always be performed with the same care and 
caution as if the mother were living, and no special directions 
need be given. 

* "Probably the child will survive the mother's decease longer, cseteris 
paribus, in proportion to the suddenness of the woman's death. If she lay 
sick, for a considerable period prior to death, the amount el' oxygen in the 
blood at the moment of dissolution is presumably less than it would he at the 
instant of sudden death in a woman previously healthy. 1 ' Dr. Underbill, vide 
Am. Jour. Obs., v. xi., p. 626. 

f " System of Midwifery," Am. Ed., 1880, p. 512. 



568 PORRO'S OPERATION. 

Post-Mortem Delivery Through the Natural Passages. — 

In some instances this will be the preferable mode of operating, 
chiefly, however, out of deference to the wishes of friends of the 
deceased mother. " People in general do not look with the same 
feelings of horror on contused as upon incised wounds. In rare 
cases the chances of saving the foetus may be almost as good by 
version as by abdominal incision; but success can be looked for 
only in exceptional instances. If labor had gone into the 
second stage before the maternal death took place, the forceps 
should be used without delay, in normal conditions of the pel- 
vis, in preference to the knife. There are a number of recorded 
cases of spontaneous expulsion after maternal death. 
Porro's Operation. 

Oophoro-Hysterectomy. — Porro's operation consists briefly, 
in tne removal, after the performance of the Cesarean section, of 
the uterus and ovaries. It is a comparatively new operation, 
its first execution on a human subject having taken place in 
1868, by Dr. Horatio E. Storer, of Boston. The patient lived 
sixty-eight hours. This operation, however, was not deliber- 
ately planned, and it was performed because of the excessive 
hemorrhage arising from the uterine incision made in the Ce- 
sarean operation. 

Prof. Edward Porro, of Pavia, on the 21st of May, 1876, hav- 
ing had encouraging results from the operation performed on 
some of the lower animals, had the courage to remove the uterus 
and ovaries from a woman who had a rachitic pelvis, with a con- 
jugate diameter of one inch and a half. Both child a«id 
mother were saved. Since that time the operation has been 
performed nearly one hundred times, and has resulted favora- 
bly in about forty per cent, of all cases. In European experi- 
ence, where the Cesarean section has been attended with an 
appalling mortality, this operation has been performed with re- 
markable success. 

The Operation. — Up to a certain point the operation differs 
not at all from ordinary hysterotomy; but after delivering the 
child and placenta, the empty organ is lifted from the abdomen, 
and the serre-nceud of Cintrac is placed around the lower seg- 
ment, just above the os internum, and the tissues constricted 
until all hemorrhage from the uterine incision has ceased. The 



POKKO'S OPERATION. 569 

uterus is then severed with a bistoury, the stump brought out 
through the abdominal wound and there held by strapping the 
serre-nceud to the patient's thigh. 

The operation as thus performed by Porro has been modified. 
Mtiller makes the abdominal incision large enough to lift the 
unemptied uterus through, and then after making compression 
above the cervix by means of the Esmarch bandage, or the wire 
ecraseur, the uterine incision is made, and delivery effected. 
This modification is an important one, but in practice has been 
found applicable to only a certain number of cases. 

The stump should be trimmed, and some regard it advisable to 
apply freely to it perchloride of iron. To sustain the pedicle 
and prevent the ligature from slipping, two long steel pins should 
be made to transfix the cervix and rest upon the abdominal walls. 

It is considered essential that this operation, like all others 
involving exposure of the abdominal viscera, be performed under 
strict antiseptic precautions. 

On the advantages and results of the Porro operation, Dr. 
Eobt. P. Harris, who is excellent authority, says:* "Examined 
in all its details in different countries, and under different cir- 
cumstances, I have formed the opinion that the Porro-Csesarean 
operation, performed under the carbolic spray, and followed by 
proper drainage and the Lister treatment, will be found success- 
ful to the woman in about one-half of all the cases of pelvic 
deformity requiring its performance, that are brought for relief 
to lying-in hospitals. What it will accomplish in private prac- 
tice, or in the United States, where but one Cesarean case in 
twenty-eight has been in hospital, I am not prepared to say." 

He also says,f "I have no objection to the introduction of the 
plans of Porro and Mtiller, except that I am not convinced of 
the necessity for so doing. In our cities, where the requisite 
number of assistants may be readily obtained, and in our hos- 
pitals, the Porro method is less objectionable; but in country 
practice, I should prefer the old operation performed early, on 
account of its requiring but little manual aid, much less skill, 
and far less time than the new one. The patient is also slower 
in recovering from gastro-hysterectomy than gastro-hysterotomy 

* Vide Glisan. "Text-book of Modem Midwifery," p. 551. 
f "Am. Jour. Obs.," vol. xiv, p. 343. 



570 LAPAEO-ELYTKOTOMY. 

as a general rule, the abdominal wound taking a longer time to 
heal." 

Laparo-EIytrotomy. — This is an operation which has been 
brought prominently to professional notice by Dr. T. Gaillard 
Thomas, and is intended as a substitute, in some cases, for the 
Cesarean operation. It consists in making an incision from a 
point an inch above the right anterior superior spine of the 
ilium, with a slightly downward curve, on a line parallel to Pou- 
part's ligament, to a point one and three-quarters inches above 
and to the outside of the spine of the pubis. In deepening this 
incision, the skin, the aponeurosis of the external oblique, the 
fibres of the internal oblique, and transversalis muscles are di- 
vided, and then the transversalis fascia, which is here dense and 
separated from the peritoneum by a layer of connective tissue 
containing fat. The superficial epigastric artery is divided and 
must be taken up. When the peritoneum is reached it is care- 
fully raised without being cut, so as to expose the upper part of 
the vagina, through an incision in which the foetus is extracted. 
In incising the vagina there is great risk of hemorrhage. There 
is also great danger of cutting the bladder and ureter, and to 
avoid these the incision should be made nearly an inch and a 
half below the uterus, and in a direction parallel to the ureter 
and the boundary line between the bladder and the vagina. The 
right side of the patient is chosen on account of the position of 
the rectum on the left. The operation has been performed but 
a few times, is not suitable to all cases, and, owing to its diffi- 
culties and special dangers, is not likely to become popular, 
hence we shall not here give at length its various steps. 

Symphysotomy. — While this operation does not commend 
itself to the good sense of the obstetricians of to-day, it should 
not be passed over in utter silence. On account of the want of 
success in Csesarean section as practiced a century ago, a sub- 
stitute for that operation was anxiously sought, and in 1768 
Sigault suggested symphysotomy. This involves a division of 
the symphysis pubis, with a view to sufficient separation of the 
innominate bones to admit of foetal extraction. It was found, 
however, that even wide separation of the bones at this articu- 
lation, did not materially add to the facility of delivery. In 
contracted pelvis, — the very pelves in which difficulty in deliv- 



SYMPHYSOTOMY. 571 

ery was sought to be overcome by the operation, the conjugate 
diameter is the one which offers the most formidable obstacle, 
and this is not materially increased by the divarication. Dr. 
Churchill concludes that, even if it were possible to separate the 
articular surfaces to the extent of four inches, we should have 
an increase of only from one-third to one-half inch in the con- 
jugate measurement. In instances of minor degrees of contrac- 
tion, this increase might be sufficient to allow the foetus to pass, 
but the risk of the operation would be too great to justify its 
adoption. 



572 



PART IV. 

THE PUERPERAL STATE. 
CHAPTEB I. 

Phenomena and Management of the Puerperal 

State. 

Importance of the Study.— "The key," says Playfair,* "to 
the management of women after labor, and to the proper under- 
standing of the many important diseases which may then occur, 
is to be found in a study of the phenomena following delivery, 
and of the changes going on in the mother's system during the 
puerperal period. No doubt natural labor is a physiological and 
healthy function, and during recovery from its effects, disease 
should not occur. It must not be forgotten, however, that none 
of our patients are under physiologically healthy conditions. 
The surroundings of the lying-in women, the effects of civiliza- 
tion, of errors of diet, of defective cleanliness, of exposure to 
contagion, and of a hundred other conditions, which it is impos- 
sible to appreciate, have most important influences on the results 
of childbirth. Hence it follows that labor, even under the most 
favorable conditions, is attended with considerable risk." 

Mortality of Child-birth. — A large amount of statistical 
information is at hand respecting the mortality of woman in par- 
turition and the puerperal state, but it is largely from hospital 
experience, and, as is well known, does not represent with any 

* " System of Midwifery," Am Ed., 1880, p. 540. 



PHENOMENA SUCCEEDING DELIVERY. 573 

degree of accuracy the results of private practice. Dr. Matthews 
Duncan,* and McClintock, f have both given us some valuable 
figures, derived from various sources, from which it would ap- 
pear that in English obstetrical practice the death rate is be- 
tween 1 to 120, and 1 to 146. According to another report by 
McClintock, J he increased his estimate to 1 in 100. Playfair 
has pointed out a source of error in these calculations, which 
should not be forgotten, viz: that they make no allowance for 
deaths occurring from other causes than those attributable to 
labor. 

Phenomena Succeeding Delivery.— The phenomena suc- 
ceeding labor may be divided into the normal and the abnormal. 
Under the latter head should be considered all those diseased 
conditions to which the lying-in woman is subject; but at this 
time we shall exclude the latter division and confine our atten- 
tion to the phenomena of a normal character which are most 
commonly observed. 

Immediately after delivery the woman usually sinks into a de- 
lightful quietude of mind and body, which is in strong contrast 
with the stormy scenes of the close of the expulsive action. 
This, however, is accompanied by a sense of profound physical 
depression, like that which is felt after any great muscular exer- 
tion. There is nearly always a certain degree of nervous shock, 
which finds partial expression in the exhaustion mentioned. It 
is also manifested by the occurrence, in quite a percentage of 
cases, of a chill, severe enough at times to produce a chattering 
of the teeth. But these symptoms soon disappear, the nerves 
become steady, and the skin warm and moist; a sleepiness comes 
over the patient, and after a short but delightful slumber, she 
awakens, greatly refreshed. In connection with this season of 
repose, which many women enjoy soon after the completion of 
labor, it should be remembered that, during it, women are some- 
times taken with hemorrhage, and awaken to find themselves 
very low from the blood-loss. There exists, then, a necessity 
for watchfulness when sleep follows within the first hour or two 
after delivery. 

* The "Mortality of Child-bed." " Edin. Med. Jour.," Nov. 1869. 
f " Dublin Quarterly Jour.," Aug. 1869. 
X " Brit. Med. Jour.," Aug. 10, 1878. 



574 PHENOMENA AND MANAGEMENT OF PUERPEKALITY. 

Post-partum Blood Changes. — The changes in the blood in- 
cident to utero-gestation, already described, have a decided in- 
fluence over the puerperal state. The hyperinosis which al- 
ready existed is now considerably augmented by the changes 
which follow delivery. The copious supply of blood which has 
been given the uterus is now turned into other channels, and 
the involution of the uterus, which now begins, throws into the 
circulation a considerable quantity of effete matter, to get rid of 
which all the excretory ducts are opened, and all the elimina- 
tive processes are set vigorously at work. These facts must be 
borne in mind as we advance in our study of the puerperal con- 
dition. 

Pulse Changes. — When the fingers are placed upon the wrist of 
a woman recently delivered, the pulse is usually found to be 
slow, regular, and firm, indicating an increased arterial pressure 
— it being an established physiological fact that as arterial 
pressure is reduced, the cardiac contractions are accelerated; 
and as it is increased, the heart's pulsations are diminished in 
frequency. In the puerperal patient this condition is probably 
occasioned by the sudden modification of the uterine circulation. 
In many cases the pulse becomes extremely slow, falling, per- 
haps, to 50 or even 40 beats per minute. If, on the other hand, 
the pulse, from any cause, becomes rapid, and continues so for 
any length of time, the case should be most carefully watched. 
A temporary acceleration does not often denote any special 
change in the woman's general condition, as the most trivial cir- 
cumstance is capable of creating it. In the wards of lying-in 
hospitals, where special opportunities for such observations are 
afforded, this has been a common experience. It is also true, as 
stated by Playfair, that the occurrence of one bad case within 
the knowledge or observation of other puerperal patients, has 
usually been observed to send up their pulse. 

Moisture of the Skin. — The activity of the skin, which was 
diminished during gestation, now becomes functionally excited, 
and, in normal states, is always soft, and moist, especially dur- 
ing the first week. Perspiration is sometimes excessive, and re- 
quires attention. It is often accompanied by a miliary erup- 
tion upon different parts, which, from its prickling, occasions 
great annoyance. Cazeaux says such eruptions were formerly 



TEMPERATURE. 575 

more common, as the result of burdening the women with cov- 
ering. 

Temperature in the Puerperal State.— In this connection 
we should also speak of the temperature of lying-in women. 
During labor it is somewhat elevated, as the result of the excess- 
ive exertion put forth, and the general perturbation of both 
mind and body. This condition continues for a short time 
after delivery, when it declines, and sometimes descends a little 
below the normal level. The fall is not often considerable. No 
great elevation is often attained. Subsequently, and during 
the first few days after delivery, there is slight increase of heat, 
caused, doubtless, by uterine involution, and the establishment 
of the lacteal secretion. There appears, as a rule, to be no milk 
fever, such as is described by the older authors, though there is 
the slight increase of heat mentioned. Rapid, but temporary, 
rises of temperature, are often observed in puerperal women, 
which may proceed from the most trivial causes. Unless an in- 
crease of temperature is attended by other symptoms pointing 
to complications of one kind or another, or unless the tempera- 
ture should continue on a high level, there is no occasion for se- 
rious apprehension. 

Fig. 262. 



The clinical thermometer. 

The following diagram illustrates the temperature of a puer- 
peral woman, taken morning and evening, during the first ten 
days, in whom no other unfavorable symptoms were manifested. 
In fact, the author is satisfied, from repeated observations, made 
on persons in their hours of quiet home life, that in conditions 
which do not present any morbid symptoms whatsoever, the 
temperature often attains 100 deg. F. 

Uterine Involution. — The uterus, after delivery, tends to re- 
sume its original volume, with an astonishing rapidity. Though 
this change does not occur with uniformity and precise regular- 
ity, since various occurrences may serve to retard the action, 
yet we find that, in general, it observes the following course: 
Immediately after expulsion of the foetus the organ contracts 
firmly, and, as elsewhere stated, may be felt through the abdom- 



576 



PHENOMENA AND MANAGEMENT OF PUERPERALITY. 



inal walls, as a hard mass, like a cannon-ball. Alternate relaxa- 
tions and contractions take place at intervals, and aid no doubt 
in the physiological process of involution. Extreme relaxation is 
a pathological state, and tends to the formation in utero of coag- 
ula, and in some cases permits profuse hemorrhage. This con- 
dition is also apt to lead to the entrance of air into the uterine 
cavity, favoring decomposition and the liability to septic infec- 
tion. 

Fig. 263. 



DAY OF THE 
DISEASE 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


PULSE 


TEMP 


M 


E 


M| E 


M| E 


M 


E 


M 


E 


M 


E 


m|e 


M 


E 


M|E 


M 


E 


95 
90 
85 
SO 

75 
70 


100" 

o 
99 



98 



9T 

o 
98 

95° 






| 












































































1 
















































































~, 




A 




/■ . 








A 
















■~\ 






\ 




\ 




f ' 
















/ 


\ 














*v 




\el 


















/ 










v-" 




























































































































































































































































































































r\ 
























/\ 
























/\ 




































A 




/ 




/\ 
























/ 








/ 








i 








/\ 




1 












7 




v 






/ 


sz 


i 


\ 




/ 












-? 














^3. 








V^" 






V 






* . 


' 




















V 












































































































' 









































Diagram showing temperature curves, above, and the pulse curves, below, in 
a normal puerperal case. 

During the first two or three days subsequently the organ does 
not diminish much in size; but thereafter the reduction is usually 
quite rapid. At the close of the first week it is found not more 
than one and one-half or two inches above the pelvic brim, and 
three or four days thereafter it cannot be felt through the ab- 
dominal walls except by conjoint touch. In many cases uterine 
involution is arrested at about this point, and, as a result, the 
Avoman suffers from pelvic discomfort until the condition is dis- 
covered, and by appropriate treatment rectified. In normal 
cases complete involution is effected in six. or eight weeks. The 
progress of uterine diminution is graphically shown by Heschl, 
from the weight of the organ at different periods. Immediately 
after delivery he found that it weighs 22 to 24 oz. ; in one week 
it is reduced to 19 to 21 oz. ; at the end of the second week it 
weighs 10 to 11 oz. ; at the close of the third week it weighs 5 to 
7 oz. ; and in eight weeks its weight is a little in excess of that 
which preceded the first pregnancy. 

This slow reduction of the u + erus in some instances occurs 



CHANGES IN UTEEINE MUCOUS MEMBRANE. 577 

without producing any pain, or even discomfort; but in other 
cases it gives rise to what have been significantly termed after- 
pains. 

Involution generally proceeds without interruption, but a vari- 
ety of causes may interfere, such as too early physical exertion, 
neglect of lactation, and laceration of the cervix uteri. 

The Excretions. — The activity of the skin has been pointed 
out. The urine also is secreted in large quantities, but difficulty 
in voiding it is often experienced on account of temporary pa- 
ralysis of the vesical cervix, or from swelling and occlusion of the 
urethra. The rectum is for a time inactive, a condition not at 
all inimical to the woman's well-being at this particular period. 
Examination of the urine reveals a trace of sugar, varying in 
quantity with the volume of the lacteal secretion, being most 
abundant when the breasts are distended, or when, from any 
cause, the milk is not drawn. 

Changes in the Uterine Mucous Membrane. — Without en- 
tering into a detailed description of the post-partum changes 
occurring in the uterine mucous membrane, it may be said that 
the cavity of the uterus is covered with clots of blood, beneath 
which is a soft, moist, reddish-gray, friable layer, found every- 
where except at the placental site. It is supposed that this mem- 
brane is formed by a new uterine mucous membrane in process 
of regeneration, after the fourth month of pregnancy. It does 
not extend into the cervical canal, but the latter contains a glu- 
tinous, transparent, and pinkish mucus. 

The placental site is elevated, and presents a mammillated, 
rounded, anfractuous surface, dotted over with coagula, which 
are removed with difficulty. The walls of the venous sinuses, 
especially at the placental site, are thickened and convoluted, and 
contain a small blood clot, while their mouths are perfectly vis- 
ible. 

The cervical mucous membrane is not exfoliated. During 
pregnancy it is simply hypertrophied, and after labor the arbor 
vitse are discernible, though in a modified form. 

Yaginal Changes.— The vagina is shortened, and diminished 
in calibre, the rugae return, and the external orifice and vulva 
soon assume much their former appearance. A strong contrast 



578 



PHENOMENA AND MANAGEMENT OF PUERPERALITY* 



is established between the conditions which are observed imme- 
diately after delivery and those now established. 

The Lochia. — The discharges which escape from the vulva 

Fig. 264. 




Section of a uterine sinus from the placental site nine weeks after delivery. 

(Williams.) 

after delivery are known as the lochia. The period of their con- 
tinuance varies, but there is generally more or less discharge un- 
til the uterus has returned to its normal, non-pregnant, size. In 
some women, who do not nurse, they persist until menstruation 
returns. At first they are composed almost wholly of blood, 
both fluid ard coagulated. Clots of some size often accumulate 
in the uterus and vagina, especially in multipara, and are dis- 
charged, with a little pain, during the first twenty-four or for- 
ty-eight hours. After the first day, the lochia consist of about 
one-third part red corpuscles, while the other matters are 
chiefly white corpuscles, blood serum, numerous epithelial 
cells, and mucus. After the second or third day the red corpus- 
cles almost wholly disappear. As soon as the lacteal secretion 
begins to be established, the lochia are greatly diminished in 
quantity, but soon again become profuse, accompanied with 



THE LOCHIA. 579 

some blood, and later, pus corpuscles; but the blood usually dis- 
appears about the close of the first week. The discharge then 
continues, yellowish-white in color, and of some consistency. At 
this stage it is sometimes called the "green waters." 

Variations in Quantity, etc.— The amount of flow varies 
widely. Instead of gradually diminishing, until final disappear- 
ance within a few weeks, it sometimes continues profuse for 
four or six weeks, without being accompanied by morbid symp- 
toms. A persistence, or occasional recurrence of a sanguineous 
discharge is generally indicative of irregular and imperfect 
progress of uterine involution. 

The odor of the discharges at times is quite offensive, even in 
those cases which present no other morbid symptoms. Such a 
condition, however, should always be looked upon with suspicion, 
since it may indicate retention of either some part of the secun- 
dines, or coagula in which putrefactive changes have been set 
up. The danger of infection may be diminished by carefully 
syringing the vagina, two or three times daily, while the offensive 
odor continues, with a mild antiseptic solution. The lochia are 
sometimes suppressed for an interval, without the occurrence of 
bad symptoms. In other cases morbid conditions begin to ap- 
pear, which, if properly treated, will often be at once arrested. 
The following indications will be found valuable. 

Lochia suppressed by cold or emotion: actcea race. 

Lochia suppressed, head feels as if it would burst: brijouia. 

Lochia suppressed, followed by diarrhoea, colic and toothache : 
cham., cauloph. 

Lochia suppressed, violent colic: colocynth. 

Lochia suppressed, from anger or indignation: colocy. 

Lochia suppressed, with tympanitic swelling of the abdomen, 
and diarrhoea: colocy. 

Lochia suppressed by cold or dampness: dulcamara. 

Lochia suppressed from fright: opium, aconite. 

Lochia suppressed, with nymphomania: vend. a. 

Lochia scanty and offensive: mix. vom. 

Lochia scanty, becoming milky; heat, without thirst: puis., 
stram. 

Lochia too profuse, with burning pain in uterine region: bry- 
onia. 



580 PHENOMENA AND MANAGEMENT OF PUEKPERAEITY. 

Lochia profuse: millefolium, trillium, chamomilla. 

Lochia profuse, excoriating, protracted: lilium. 

Lochia milky, too protracted: cole. carb. 

Lochia long-lasting, thin, offensive, excoriating, with numb- 
ness of the limbs: curb. an. 

Lochia vitiated and offensive; lasts too long, or often returns: 
rhus tox. 

Lochia protracted; great atony: cauloph. 

Lochia protracted; drawing about ovaries; discharge fetid, 
cheesy, or purulent: china. 

Lochia protracted, profuse, excoriating: lilium. 

Lochia acrid, fetid; great prostration: baptisia. 

Lochia offensive, feels hot to the parts: belladonna. 

Lochia brown, foul smelling: carb. veg. 

Lochia very offensive and excoriating; repeatedly almost ceases 
only to freshen again: creosoinm. 

Lochia dark, Aery offensive; scanty or profuse; painless, or ac- 
companied by prolonged bearing pain: secale. 

Lochia offensive, irritating; sepia. 

Lochia increased; pain in back when nursing: silicea. 

Lochia return when she first gets about: aconite. 

The Lacteal Secretion.— The mammae for some time before 
labor are furnished with a variable quantity of a peculiar fluid 
known as colostrum, which contains a number of large granular 
and fat corpuscles, and some milk globules. Within the first 
two or three days this is succeeded by the proper lacteal secre- 
tion, the establishment of which is sometimes attended with a 
slight acceleration of pulse and elevation of temperature, and 
also some restlessness and headache, which condition was for- 
merly termed the "milk fever." These phenomena generally dis- 
appear as soon as the secretion has been well established and 
the breasts properly cared for. The profession is rapidly com- 
ing to believe that " there can be little doubt that the impor- 
tance of the so-called milk fever has been immensely exagger- 
ated, and its existence, as a normal accompaniment of the 
puerperal state, is more than doubtful." Out of 423 cases re- 
ported by Macan,* in 114 there was no rise of temperature. A 
number of recent writers on the subject refer the phenomena 

*" Dublin Jour, of Med. Seience," May, 1878. 



THERAPEUTICS. 581 

described to coincident septic influences. Moreover, since they 
appeared to be much more commonly observed in the days when 
the practice was to keep puerperal women on a low diet, it may 
be that this element exercises a controlling influence. From 
careful observation, we are led to believe that the symptoms in 
question, when present, owe their existence mainly to the irri- 
tation proceeding from over-distension of the breasts. Decided 
relief is at once afforded by emptying them. 

The lacteal secretion does not make its appearance in every 
case. When, from any cause, a considerably elevated tempera- 
ture follows closely upon delivery, the milk may utterly fail to 
appear. In rare cases, it would seem, as Dubois has remarked, 
that nature has left her work unfinished in some women. They 
are capable of becoming mothers, and are able to provide suita- 
ble nourishment for their children throughout the period of ges- 
tation, but their economy does not provide for their want after 
birth. 

Therapeutics. — Secretion Abundant — Breasts greatly and 
painfully distended with milk: acet. ac. 

Secretion too abundant: cede, carb., uranium, Pulsatilla. 

Excessive flow of milk, causing great exhaustion: phytol. 

Secretion Deficient — Milk scanty or absent; despairing sad- 
ness: agnus c. 

Deficiency of milk with over-sensitiveness , asafoet 

Scanty secretion of milk: bryonia. 

Mammae distended, but milk scanty : cede. c. 

Little milk in mild, tearful women, presenting no morbid 
symptoms: pulsed diet. 

Milk scanty or vitiated; child refuses it: mere. 

Scanty milk, with debility and great apathy: phos. ac. 

The secretion is not established; stinging in the breasts: 
secede. 

Insufficiency of milk, or entire failure to appear: urtica turns. 

Quality of Secretion.— -Milk watery and thin: calc. phos. 

Milk thin, blue; patient sad and despairing on waking: lach. 

Milk yellow and bitter, child refuses the breast: rheum. 

Pain in the back on nursing; increase of lochia: flow of pure 
blood. Complains every time the child takes the breast: sdicca. 



582 PHENOMENA AND MANAGEMENT OF PUEKPEEALITY. 

Means for Arresting the Secretion of Milk.— When from 
any cause lactation is not performed, the breasts require most 
careful attention. They are liable to become distended, heated 
and painful, and, if not properly treated, inflammation and sup- 
puration may ensue. 

We believe the best sort of general treatment of these patients 
is the expectant one. It is unwise to tamper with the breasts 
at all unless they become hard and painful. Meanwhile they 
should be kept warm by the application of a layer of cotton, 
over which may be laid a piece of oiled silk. If the distension 
becomes excessive, it should be partially relieved by drawing 
only a small quantity of the secretion. If they become hard and 
lumpy the nurse should be instructed to freely apply warm oil 
and rub them in a gentle manner, always making the passes to- 
ward the nipple. If in any case inflammation begins, hot fo- 
mentations should be faithfully followed, until the pain and 
soreness disappear. A most excellent manner of applying the 
heat is to take a basin of sufficient size, and line it with two or 
three thicknesses of flannel wrung out of water as hot as can be 
borne, and then place it over the breast. By this means the 
heat can be retained for a long time. 

In certain cases we may think best to subdue the functional 
activity of the gland by the use of camphorated oil. We believe 
the use of belladonna plasters, as recommended by some, unwise 
practice. 

The remedies which give the best results in the way of reduc- 
ing the quantity of the secretion are belladonna, urtica urens, 
and bryonia. If inflammatory symptoms supervene, the reme- 
dies mentioned under the head "Mammary Abscess" should be 
employed. 

After-Pains. — True after-pains are produced by uterine con- 
tractions, usually excited by the presence in utero of coagula. 
They occur much more frequently inmultiparse than in primip- 
arae, because, in the former, the uterine cavity is larger, and 
the rigidity and tonicity of fibre observable in primiparse has, 
in a measure, been lost. They are to a certain extent preventa- 
ble, and prophylactic means are those which favor firm contrac- 
tion of the uterus, in which abdominal pressure and kneading 
take a prominent place. The pains generally begin soon after 






TREATMENT OF AFTER-PAINS. 583 

delivery, and are recurrent, like those of labor. In exceptional 
cases they are extremely severe. Application of the child to 
the breast, though a wise proceeding, increases the intensity of 
the after-pains. Their period of duration varies, seldom being 
protracted beyond two or three days. In some cases, after hav- 
ing disappeared, they return for a time, and again leave after es- 
cape of a retained coagulum. They are sometimes so severe as 
to extort cries, and are dreaded by many women almost as 
much as the pains of labor. 

After-pains should not be confounded with the pains accom- 
panying peritoneal inflammation, and may generally be distin- 
guished by the absence of high temperature and rapid pulse. 

The uterus sometimes appears to be in a condition of hyper- 
esthesia, wherein the intermittent contractions, which charac- 
terize the puerperal state, unassociated with the presence of co- 
agula, occasion much suffering. Dewees mentions a pain of 
frightful intensity which is experienced by some women in the 
lower part of the sacrum, and in the coccyx. It begins soon af- 
ter delivery, and, unlike real after-pains, it is continuous. 

Treatment. — When after-pains plainly depend on the pres- 
ence in utero of coagula, pressure judiciously applied to the fun- 
dus uteri will sometimes afford relief, by evacuating the organ. 
When of a neuralgic character, heat to the abdomen will be 
found agreeable and beneficial. 

There is no question that the prompt administration of 
arnica, after delivery, has a modifying influence upon this va- 
riety of suffering; while, in some cases, it serves as an efficient 
prophylactic. Other remedies are often of great service, and 
some of the indications for their use here follow: 

After-pains extremely severe and long-lasting: aconite, nux r. 

After-pains too long, or too violent; worse toward evening: 
puis. 

After-pains too long and severe; though cold she does not 
wish to be covered: secale. 

After-pains of a cramping nature, often attended with cramps 
in the extremities : cuprum. 

After-pains worse in the groins; over-sensitiveness: nausea 
and vomiting: actcea rac. 

After-pains violent; return when the child nurses: arnica. 



584 PHENOMENA AND MANAGEMENT OF PUERPEKALITY. 

After-pains, excited by the least motion, even taking a deep 
inspiration: bryonia. 

After-pains especially after long hard labor, spasmodic across 
the hypogastriuni, extending into the groins: caidoph. 

After-pains very distressing, especially in women who have 
borne many children : cuprum m. 

After-pains violent in sacrum and hips, with severe headache, 
especially after instrumental delivery: Hypericum. 

After-pains with much sighing: ignatia. 

After-pains with great sensitiveness of the abdomen: scibina. 

After-pains of a severe bearing character, as if everything 
were being forced out: belladonna. 

After-pains come and go suddenly; (especially good for neu- 
ralgic pains: ) belladonna. 

After-pains very distressing, and the patient extremely irrita- 
ble: chamomilla. 

After-pains which produce a desire to defecate: nux v. 

After-pains colicky, causing her to bend double: coloey. 

After-pains producing faintness: nux vom., pulsatUla. 

After-pains worse at night; she wants the room warm, and 
must be well covered: rhus fox. 

After-pains accompanied with burning and bearing: terebinth. 

Necessary Attentions to the Puerperal lVoman. — The pu- 
erperal patient requires plenty of fresh air, without exposure, 
wholesome food, quietude, and cleanliness. In warm weather 
the doors and windows should be opened often enough to keep 
the air of the room fresh and pure, while everything about the 
apartment which tends to contaminate should be scrupulously re- 
moved. The room selected for the confinement should not be 
near a water-closet, or bath-room, and should have no stationary 
washbowl, as more or less foulness is emitted by all such con- 
nections with a sewer or cess-pool. The bed should be placed 
so that the patient will not be in the line of a draft when the 
doors and windows are opened. In the cold seasons the temper- 
ature of the room should be kept as even as possible, and should 
approximate 65° to 70°. The vulva ought to be washed with 
warm water soon after delivery, and the soiled clothes removed. 
Cn no account should the woman be permitted to lie with them 
under her for several hours. The napkins will require frequent 
changing. 



THE physician's VISITS. 585 

The Physician's Visits.— The puerperal condition is one in 
which sudden and alarming changes are liable to occur, and the 
physician should see his patient every day during the first week. 
The interval between delivery and the first visit ought not to 
exceed twelve hours. At each visit during the first two or three 
days, in normal cases, in addition to the ordinary observations, 
the uterus should be examined by placing t.be hand on the abdo- 
men, the temperature taken, and the urinary and lochial dis- 
charges inquired after. The condition of the breasts will also 
demand his attention. 

The woman after labor sometimes finds herself unable to uri- 
nate, owing, in some cases, to temporary vesical paralysis, in 
others to swelling of the urethra, and occasionally to muscular 
spasm. In such cases aconite will now and then afford speedy 
relief. In case of failure, belladonna may succeed. The reme- 
dies should be given at intervals of only five or ten minutes, for 
an hour. Cloths wrung out of hot water, and laid over the vulva, 
will occasionally give relief. But, in case both topical applica- 
tions and internal remedies fail, a soft catheter should be care- 
fully passed. Subsequently it may be necessary, for a time, to 
use the catheter night and morning. These are some of the 
most important considerations in connection with puerperal 
women, and must not be disregarded. We have directed special 
attention to the foregoing remedies, but the following may also 
be found serviceable: 

Eetention of urine: aconite, bell, camphor, hyos. 

Ketention of urine with stitches in the kidneys: aeon., canth. 

Eetention of urine without desire to urinate : arsen. 

Ketention of urine with frequent ineffectual desire, or with 
urging to stool : nux vom. 

Desire to urinate, accompanied with great distress, fear and 
anxiety: aconite, 

Has to strain at stool in order to urinate: alumina. 

Tenesmus of the bladder : mere. c. 

Regimen. — The regulation of the diet of lying-in women has 
been thoroughly revolutionized during the past few years. The 
older custom was to keep them on food of the lightest kind, and 
in small quantities for several days succeeding delivery; but it 
has now become customary to prescribe good nourishing food in 



586 PHENOMENA AND MANAGEMENT OF PUERPERAlITY. 

liberal quantities. There is danger, however, of falling into an 
error in this direction, and thereby destroying the benefits 
which are derivable from a well-regulated regimen. Our best 
guide in the matter are the patient's feelings. If she has no 
appetite, it would be unwise to insist on a generous diet; but, 
on th,e contrary, if the appetite is good, we may safely be more 
generous. Part of a cup of beef tea, a glass of milk, an egg 
beaten up with milk, or some toast may be given soon after la- 
bor. If there is a desire for it, a few mouthfuls of beef or 
chicken may be given after the first day. When lactation has 
become established, the restrictions on diet may be almost 
wholly removed, after cautioning the patient against over-load- 
ing the stomach. Less care will be required in the case of ro- 
bust women, than those who are delicate; and, while we feed 
the latter well, we should be exceedingly careful about both the 
quality and quantity of their food. Stimulants, as a rule, should 
be avoided. 

The Bowels. — It is the custom in old-school practice to pro- 
voke a movement of the bowels on the second or third day, and 
to bring it about, recourse is generally had to cathartics of va- 
rious kinds. This we cannot but regard with disfavor, both in 
respect to the time of movement, and the mode of eliciting it. 
In the latter days, or hours, of pregnancy, there is generally a 
relaxed state of the bowels. When this is not true, an enema 
should be given in the early part of labor, and the rectum en- 
tirely emptied. This having occurred, there is no crying neces- 
sity for further action during the succeeding four or five days, 
unless ineffectual desire is sooner manifested. On the fourth or 
fifth day a few doses of nux vomica may be given, and, if nec- 
essary, a full enema of tepid water and soap. If there is earlier 
desire, without favorable result, it will be wise, in the absence 
of inflammatory complications, to give a small enema. If the 
woman has been, or is, suffering from inflammatory action in the 
pelvic region, the regulation of the bowels will require most 
careful attention. 

In exceptional cases the bowels are loose after delivery, the 
treatment of which condition will be but little modified by the 
puerperal state. 

Time for Getting Up.— Many women claim to feel as well, 



TIME FOR GETTING UP. 587 

and almost as strong, immediately after labor as before, and it 
is impossible to impress them with the necessity of keeping the 
bed for eight or ten days, as the prescription generally is. It 
should be remembered, however, that this question of rest is the 
most important one in connection with either normal or abnor- 
mal lying-in. The experience of the laboring women of foreign 
birth, who generally get about on the third or fourth day, is 
pointed to by some as evidence of the harmlessness of the prac- 
tice of early rising from the puerperal bed. We admit that it is 
not so much the danger of immediately serious effects that we 
fear in such cases, as the weakness and derangements which are 
apt to ensue, and torture the patient for long months or years. 
And when we have an intimate acquaintance with the physical 
condition of those who disregard physiological laws respecting 
the lying-in state, we find that they are laden with ailments, and 
bear about with them the evil effects of their indiscretions. 

Still, the habit of keeping the woman on her back for a week 
or two following parturition, is a very injurious one. She should 
be allowed to sit upright to urinate and defecate, and by this 
means all cuagula and retained lochia will be permitted to escape 
from the vagina. 

During the first few days the puerperal woman should be 
kept quiet, and free from annoyance; and no garrulous neigh- 
bor should be permitted to disturb her repose of mind and 
body. She will do well to keep her bed for nine or ten days, no 
matter how strong or well she may feel; and for at least a week 
subsequently, more than half her time should be spent in a re- 
cumbent posture. If she will contentedly remain longer, so 
much the better, as the normal post-partum changes will be more 
satisfactorily accomplished. In considering the question of rest 
after delivery, the fact that the uterus does not complete its in- 
volution under six or eight weeks, should be kept prominently 
in mind; and that an early getting up is harmful, largely be- 
cause it interferes with the prompt and full accomplishment of 
this physiological process. 

There is but a single further caution to be offered in this con- 
nection, and that is, that care be taken in the instance of feeble, 
nervous women, not to permit them to go to the opposite ex- 
treme, and lie in bed too long. Some women require almost to 



588 CAKE OF THE CHILD. 

be driven out of bed. Every little discomfort is magnified, and 
made a pretext for acting the part of an invalid. The manage- 
ment of such cases requires the most consummate discretion 
and tact. 

Cake of the Child. 

The temperature of the room in which the child is to be washed 
and dressed should not be below eighty degrees, and as the com- 
fort and well-being of the mother is not compatible with so 
great heat, these attentions should be given in another room. 
At the time of birth the child is covered with a layer, more or 
less thick, of vernix caseosa, which cannot be easily removed 
without first being treated to a thorough application of oil or 
lard. The bath should not be prolonged, and at its close the in- 
fant will be wrapped in flannel and laid aside for a time, or com- 
pletely dressed. The stump of the cord should be rolled in a 
piece of raw cotton, or laid between folds of silk or old linen, 
and then covered by the flannel band. The condition of the 
navel after separation of the cord will depend in some measure 
upon the treatment bestowed at the time of birth. It is the 
practice of a goodly number of able practitioners to await the 
cessation of pulsation in the cord, or not, and then sever it with- 
out applying a ligature. That the practice, if properly followed, 
is a safe one, we are fully satisfied from considerable experi- 
ence. The cord should be held between the thumb and fingers 
and cut with a pair of blunt scissors. If bleeding follows, the 
stump should be held for a moment, and then stripped between 
the fingers. As soon as bleeding has once ceased, the child may 
be considered safe. Still, like those cases wherein ligation is 
practiced, it is wise to examine the stump occasionally during 
the first half hour. While we do not recommend this innovation, 
we can see no rational objection to it. We have no question 
that it is more in accordance with physiological conditions, and is 
less liable to be followed by umbilical irritation and ulceration. 

Should the navel become inflamed, or severely irritated, in 
any case, we should enjoin perfect cleanliness, to be practiced 
without friction, and with the application, if necessary, of ly co- 
podium. 

The child will require no nourishment from the start but that 
which it derives from the maternal breasts. The early secre- 



PHLEGMASIA DOLENS. 589 

tion — colostrum — has a laxative effect on the child's bowels, 
while at the same time it affords some nourishment. It is ad- 
visable, as a rule, to put the infant to the breast early, not only 
for its own benefit, but also for the good of the mother. In 
those unfortunate cases where the mother is unable to nurse her 
child, or it is thought inadvisable for her to do so, we have to 
provide either a wet nurse, or an artificial diet. A discussion of 
this subject we shall omit, and refer the student to special trea- 
tises on the subject, and to works on diseases of children. 



CHAPTEE II. 

The Puerperal Diseases, 

Phlegmasia Alba Dolens, or Milk Leg.— This morbid state 
has attracted a great deal of attention and study, and yet opin- 
ions differ respecting both its nature and origin, though it seems 
to be pretty generally admitted that the symptoms and pathol- 
ogy of the conditions in question owe their existence to the for- 
mation of thrombi in the peripheral venous system. 

The disease is not limited to the puerperal state, nor even to 
women, though these are the conditions under which it com- 
monly occurs. It attacks by preference the left leg; but some- 
times it assails the right, and occasionally is bilateral. 

The Symptoms. — The period of invasion is most frequently 
between the end of the first and third weeks after delivery. The 
real onset of the disease is generally preceded by a feeling of 
great depression, restlessness, irritability, fever, and commonly 
more or less pain in the uterine region. After a time, repeated 
chilliness or a distinct rigor is experienced, accompanied, or 
followed, by distressing pain, usually in the calf of the leg. The 
pain is sometimes primarily felt in the ankle, knee, groin or hip. 
"When first examined there is no redness or swelling, but within 
twenty-four hours the leg becomes oedematous, white and shin- 
ing. When the swelling begins in the groin or hip, its course 
is usually downwards, but when the pedal extremity is the point 
of first attack, its course is reversed. The swelling in some 
cases does not extend above the knee. When the entire limb is 
involved, the femoral vein is always hard, distinct and painful, 



590 THE PUERPERAL DISEASES. 

when touched by the finger. The pains seem to follow the course 
of the inflamed and obstructed vessels. Occasionally the track 
of the vein can be traced by an observable redness; but the re- 
verse of this is more frequently true. When the leg is the part* 
affected, the veins on the inner side of the limb and in the pop- 
liteal space are more particularly involved. Sometimes the lym- 
phatics are also painful, and the inguinal glands are enlarged 
and sensitive. The limb, which at first would easily pit on pres- 
sure, after a time becomes so distended as to admit of the pro- 
duction of no such effect. 

Marked constitutional symptoms are also developed. The 
pulse ranges from 100 to 150, and the temperature from 102 ° 
to 106 ° . The tongue is rather dry, the stomach irritable, and 
the skin, though hot, is usually moist. The pain is so severe 
that the patient can get but little sleep, and she is nervous and 
irritable. The disease reaches its height in a period varying 
from seven to fourteen days, and then begins gradually to decline. 
The pain becomes less excruciating, and the tension of the limb 
less marked, while the pulse and temperature begin to fall. In 
unfavorable cases, little vesicles appear in certain parts of the 
affected member, or over the whole of it. In some cases the 
lymphatic glands suppurate; abscesses form in the cellular tis- 
sue, or the joints become the seat of inflammation and suppura- 
tion. In rare cases, the symptoms, on declining in one of the 
lower extremities, appear in one or both of the upper limbs. In 
any case, considerable time elapses ere the affected part regains 
a size which approximates the original. In most instances there 
remains more or less permanent enlargement, and unusual ex- 
ercise on the feet causes the member to swell. Patients who 
have once suffered from the disease are prone to a recurrence of 
it in subsequent confinements. 

In the worst cases death may take place from exhaustion, or 
may come suddenly from pulmonary obstruction due to em- 
bolism. 

Etiology and Pathology. — Mauriceau gave a very good de- 
scription of the symptoms of phlegmasia dolens, the pathology 
of which he regarded as " a reflux on the parts of certain Jiumors 
which ought to have been evacuated by the lochia." Puzos sup- 
posed them to be due to an arrest of the lacteal secretion, and 



PHLEGMASIA DOLENS. 591 

its extravasation into the tissues of the affected limb. Many 
subsequent theories were advanced, among the most popular of 
which was that which attributed the symptoms to some morbid 
condition of the lymphatic glands and vessels of the affected 
part. 

Subsequently, but not till 1823, was the existence of coagula 
in the veins, presumed to result from inflammation, pointed out, 
which gave to the disease the name of " crural phlebitis." Dr. 
E. Lee, on careful dissection, found coagula also in the iliac and 
uterine veins, from which fact he inferred that the disease be- 
gan in the uterine branches of the hypogastric veins, and ex- 
tended downward to the femorals. He also drew attention to 
the occurrence of phlegmasia dolens in connection with other 
conditions which were liable to produce phlebitis, such, for ex- 
ample, as carcinoma of the cervix uteri. This theory is still 
held by some. 

Dr. Mackenzie, and others, have since experimentally demon- 
strated that inflammation of the veins is not of itself sufficient 
to produce the extensive thrombi which are found to exist, and 
that inflammation shows no marked disposition to extend along 
the course of a vessel. The morbid conditions of the veins were 
accordingly attributed to an altered or septic state of the circu- 
lating fluid. 

Dr. Tilbury Fox* believes the thrombi to originate from either 
extrinsic or intrinsic causes, the former being pressure from 
tumors, and the like, and the latter: 1. True inflammatory 
changes in the vessels, as seen in the epidemic form of the dis- 
ease. 2. Simple thrombus, produced by rapid absorption of 
morbid fluid. 3. The conjoined action of virus and thrombi, the 
phlegmasia dolens itself being the result of simple thrombus, 
and not of the inflamed coats of the veins. The swelling of the 
affected part he regards as not attributable to oedema alone, but 
to oedema and obstruction of the lymphatics. The efficient cause 
of these changes, he believes, is usually septic action originat- 
ing in the uterus, producing a condition similar to that which 
gives rise to phlegmasia dolens in the non-puerperal state. 

While no one of these theories can be adopted in its entirety, 

* Obstet. Trans., vol. ii. 



592 THE PUERPERAL DISEASES. 

we may regard the essential point in the pathology of this dis- 
tressing disease, as thrombosis in the veins. 

Treatment. — "The prophylaxis in this disease is very im- 
portant." We quote Dr. Joseph Amann.* If signs of fever 
and pain in the limb appear, the patient should remain in bed, 
receive no visits, and observe strict diet. Every precaution 
should be taken to remove all causes of excitement or irritation, 
moral or physical. 

"An important point is the position of the patient; she should 
lie so that the leg of the affected limb is more elevated than its 
thigh. For this purpose, the leg should be laid on a soft, elas- 
tic cushion, the knee being bent." 

It is well to rub the affected limb gently two or three times a 
day with cosmoline, the passes all being made toward the trunk. 
At other times it should be enveloped in cotton batting, and 
covered with silk. 

After the period of acute tension has gone by, the leg- should 
be subjected to a careful examination for the purpose of ascer- 
taining whether there is any circumscribed collection of pus, 
and if found it should be freely evacuated. As soon as the 
limb is in a condition to bear it, a roller bandage should be ap- 
plied from the toes to the hip, and renewed from time to time, 
as long as there remains any oedema. The patient should not 
be permitted to put her foot to the floor, until all evidence of 
the disease has disappeared. 

The homoeopathic remedies specially suited to this disease are 
few in number. When at the outset the temperature runs up, 
the skin is dry, the pulse rather rapid, and the patient restless, 
we cannot do better than administer aconite. 

With similar symptoms, and a full and hard pulse, showing 
high arterial tension, verairum viride may be given. 

Belladonna is probably the remedy from which we will derive 
the most benefit after the first twenty-four hours, especially if 
the pains are sharp, the patient is less restless, and not so thirsty. 
Often we will do well to continue this remedy for three or 
four days, unless the symptoms point more directly to some 
other. 

* Klinik der Wochenbettkrankheiten, 1877. 



PUEKPEKAL MANIA. 593 

Bryonia will be found of service when the pains are sharp 
and shooting, and the suffering is greatly aggravated by every 
movement. 

Pulsatilla should be substituted for, or given in preference 
to, either belladonna or bryonia if there is no thirst, and the 
temperament or mood is peculiarly mild and tearful. It should 
also succeed either or both of the other remedies when the case 
is not progressing favorably under their influence. 

Hamamelis doubtless has a decided influence over the course 
of the disease in certain cases, and should occupy a prominent 
place among the remedies suited to it. 

Arsenicum, sulphur, calcarea carb., and other remedies are 
sometimes called for. 

Pueepeeal Mania. 

The term "puerperal mania," is intended to include all those 
cases of mental aberration occurring in connection with the 
pregnant, parturient and puerperal states, which might come un- 
der the more comprehensive title of insanity. Such conditions 
when developed during pregnancy are usually brought about 
by the hysterical temperament, by injudicious moral manage- 
ment, by neglect of the excretory functions, by sudden shocks, 
and by hereditary predisposition to insanity. In parturition, 
the agony of the occasion may be so intense as to arouse a 
nervous, excitable temperament to the very height of frenzy. It 
is more likely to occur just as the head passes the vulva, and in 
primiparse. This form of insanity can generally be prevented 
by judicious use of chloroform.* 

Classification. — The term puerperal mania is more especially 
applicable, however, to that form occurring during the puerpe- 
ral state, and it is of this that we shall more especially speak. 
We may conveniently divide it into two classes: 1. Puerperal 
insanity, properly so called; that is, insanity which is developed 
within the first two or three weeks after delivery; and 2. The in- 
sanity of lactation. The former is the more frequent. 

Frequency. — As regards the frequency of these affections, 
out of 1,644 women in the Bethlehem Hospital, 84 wore 

*Dr. Tyler Smith says he has seen cases which apparently depended on the 
use of large quantities of chloroform during labor. 



594 THE PUERPERAL DISEASES. 

cases of puerperal origin; and of 1,119 cases in La Salpetriere, 
94 were cases of this kind. 

Puerperal Insanity. — In this variety the attack generally be- 
gins within the first two or three weeks after delivery, and may 
assume a melancholic form, or it may be acute, and attended with 
violent delirium, high fever and great constitutional disturbance. 
The latter occurs much more frequently at a period soon after 
delivery, than the former. Tuke found that all cases of acute 
mania were developed within the first sixteen days after deliv- 
ery, and that all cases of melancholia developed themselves 
after that time. 

One of the first symptoms of the approach of acute mania is 
insomnia. Many times there is total want of sleep, and the 
mental exhaustion which results doubtless adds to the severity 
of the attack. The countenance is flushed, the head aches, the 
eyes have an unusual lustre, and they rest with a wild uneasi- 
ness on objects before them. The temper is irritable; the lacteal 
secretion is diminished in quantity, and after a time totally sup- 
pressed; and the memory is defective. The woman becomes lo- 
quacious, and her ideas are constantly varying, and disconnected. 
It often happens, however, that there is a fixed notion, or an im- 
perfectly formed idea running through her incoherent talk, and 
this is extremely apt to be of a sexual nature. °The patient is at 
times demure and morose, and then again highly excited and 
fairly raving. She may tear her clothes from her body, and at- 
tempt self-destruction, or the life of others. She sometimes 
bites, strikes and tears at a frightful rate, and again puts the 
body through motions which indicate a nymphomaniacal condi- 
tion. The temperature is always high, varying from 101° to 
105°. The bowels are generally confined, the urine turbid, and 
the tongue coated. Acute mania often accompanies puerperal 
septicaemia. It is also dependent in some cases on inflamma- 
tion of the pelvic organs or the contiguous tissues, such as pel- 
vic peritonitis, cellulitis, and metritis. It is occasionally associ- 
ated also with inflammation in other and distant organs. 

Acute mania, if prolonged, may finally take on the melan- 
cholic type, and become intractable; but this form of the dis- 
ease is generally idiopathic. The advent is gradual, beginning, 



PUERPERAL MANIA. 595 

perhaps, with depression of spirits, insomnia, indigestion, 
headache and other indications of physical derangement. 

Insanity of Lactation. — This generally proceeds from the 
excessive drain placed upon the energies by over-lactation, in 
the instance of women with delicate, highly nervous organiza- 
tions, or of those who have been reduced by illness. The essen- 
tial pathology is brain anaemia. Such patients do not often pre- 
sent the violent symptoms of those suffering from puerperal 
mania, and when they do, the attack is usually of short dura- 
tion. 

Prognosis. — The prognosis of recent cases of puerperal ma- 
nia and the insanity of lactation, is exceedingly hopeful. " It 
is, perhaps," says Tuke, " the most curable form of insanity." 
Its duration is sometimes but a few days, especially in those 
cases which follow puerperal convulsions. "In a majority of 
cases," remarks Barker,* "the mania gradually subsides with- 
in a period of three weeks, more frequently earlier, and is fol- 
lowed by a condition of partial dementia, with some delusions, 
especially as regards personal identity. These gradually disap- 
pear, leaving a kind of intellectual barrenness, like one waking 
from a dream. From this condition, you may confidently hope 
for ultimate recovery. In some cases, the malady is prolonged 
two or three or more months ; but, if beyond six months, the 
chances of recovery are very small. When death is the result, 
it is almost invariably due to some associated disease, as peri- 
tonitis, or cellulitis, pneumonia, and in "some exceedingly rare 
cases, phrenitis, the fatal result usually occurring in a very few 
days." 

Canses. — Hereditary tendencies exercise a strong predisposing 
influence, traceable more frequently to the female side of the 
family. A condition of mental depression and physical exhaus- 
tion favors its development. Difficult labor should also be classi- 
fied among the prominent predisposing causes. Out of seventy- 
three cases of Dr. Tuke, the labor was complicated in twenty- 
three. To these may be added anaemia and eclampsia. 

Barker f has conclusively shown that mental and moral 

* " The Puerperal Diseases," p. 175. 
f Barker, loc. cit. p. 177. et seq. 



596 THE PUERPERAL DISEASES. 

emotions are the most common exciting cause of puerperal mania. 
Morbid dread during pregnancy, insufficient to produce insanity 
before delivery, may develop into mental derangement after it. 
Shame and fear of exposure in unmarried women not unfre- 
quently lead to it. 

Sir James Simpson attributed the development of puerperal 
mania to a morbid state of the blood. Others have found its 
origin in the peculiar state of the sexual system which succeeds 
labor. 

Treatment. — The general indications are for the supply of 
good nutritious food, and plenty of sleep, to accomplish both of 
which is sometimes a matter of considerable difficulty. 

Food that is known to possess an abundance of nutritious 
elements and to be easily assimilated, should be prepared in the 
most tempting form in order that the patient may be willingly 
induced to take it. There is little danger of over-feeding such 
women. In some cases food is obstinately declined, when it 
becomes necessary to forcibly administer it. When given under 
such conditions, it should be fluid rather than solid, both to favor 
speedy digestion, and obviate the risk of choking the patient. 
But before resorting to force, every gentle and persuasive means 
should be employed to overcome the obstinacy which is evinced. 
Stimulants are not only of no service, but they are capable of 
doing positive harm. 

To calm the nervousness and excitement which induces the 
insomnia, the well-selected homoeopathic remedy is generally 
adequate; but should our keenest discrimination and most intel- 
ligent selections utterly fail to make the designed impression, it 
will be a matter for each physician to determine whether he 
shall resort to the hypnotics employed by old-school practition- 
ers, or allow the symptoms to remain unsubjugated. Opiates 
have not proved efficacious and have often done positive harm. 
The first effect of a hypodermic injection of morphia is favora- 
ble, but the symptoms are subsequently decidedly aggravated. 
Chloral hydr.ate has thus far served the best purpose, either 
alone, or in connection with bromide of potassium. If given at 
all, the dose should be from fifteen to thirty grains, to be ad- 
ministered at bed-time. Its action is generally quite satisfac- 
tory. 



PUERPERAL MANIA. 597 

The general care of the patient should be most considerate. 
She must have a well-ventilated room, in a quiet part; all undue 
exertion should be gently restrained; and the presence of any 
person, or any thing, which irritates or excites her, should be 
interdicted. 

With regard to the therapeutics of puerperal insanity it should 
be said, that, inasmuch as the mental and moral symptoms are 
oftentimes associated with, and probably the result of certain 
inflammatory affections of different parts, and in other cases the 
consequence of excessive physical debility, they alone should 
not constitute our guide to the selection of remedies, though 
they should usually be given greater weight than any others in 
our estimate of the relative value of symptoms. We should not 
expect too much from our remedies, but their action must be 
encouraged and sustained by the strict observance of hygienic 
rules. 

The following are some of the most prominent mental and 
moral symptoms of the more common remedies: 

Mood, etc. — Low spirited, out of humor, inclined to weep: 
sulphur. 

Strong disposition to sadness : lachesis, natrum mur., Pulsa- 
tilla, sepia, igncdia. 

Despairing sadness, with milk scanty or suppressed: agnus 
cast 

Melancholy mood, looks on the dark side of everything: caus- 
ticum, aetata vac. 

Sad about her health and domestic affairs: sepia. 

Mania arising from indignation or grief: colocynth. 

Bad effects from grief, chagrin, unhappy love: phos. ac. 

Desire to commit suicide: aurum, rhus tox., nux vomica. 

Continual thought of suicide: aurum. 

Eestless; fears death, and predicts its time: aconite. 

Great fear of death and of being left alone: arsenicum alb., 
lycopodium. 

Great anguish, extreme restlessness and fear of death: arsen- 
icum, aconite. 

Extreme fear of death; sleeplessness: coffca. 

Fear of being poisoned : hyoscyqmus. 

Fears an internal incurable disease: I ilium. 



598 THE PUERPERAL DISEASES. 

Apprehends some misfortune: calcarea carb. 

Starting and fear on awaking: stramonium. 

Shuddering and dread as evening draws near: calcarea carb. 

Very irritable and wishes to be alone: nux vom. 

Desires to be alone; taciturn, sad: ignatia. 

Paroxysms of rage and fury: belladonna. 

Exceedingly irritable: bryonia, chamomilla, nux vomica. 

Mania excited by anger: chamomilla, colocynth. 

Mania from fright, with grief: gelsemium, ignatia. 

Mania from fright, with indignation : aconite. 

Apathy; scanty lacteal secretion: phosphoric ac. 

Great indifference: phosphoric acid, sepia. 

Indisposed to talk: phosphoric acid. 

Taciturn, haughty: veratrum alb. 

Great loquacity: stramonium. 

Very haughty: platina. 

Gay, cheerful: lachesis, crocus. 

Lascivious furor, without modesty: hyoscyamus. 

Wants to kiss every one: veratrum alb. 

Mental Oppression. — Appears as if stunned: belladonna. 

Mania from fright, with sopor: opium. 

Confusion of mind, — cannot connect her thoughts : gelsemium, 
baptisia. 

Mental Agitation. — Mania from fright, with vexation; circu- 
lation excited, rapid respiration: aconite. 

Wild feeling in the head as though she would be crazy: 
lilium. 

Hallucinations, Delusions, Illusions, etc. — Imagines there is 
another baby in bed requiring attention: petroleum. 

Muttering; does not know her friends: hyoscyamus. 

Singing, delirium: stramonium, hyoscyamus. 

Unceasing talking, singing and imploring: stramonium. 

Loquacious delirium, with desire to escape: belladonna, stra- 
monium. 

Delirium, with frightful figures and images before the eyes: 
stramonium. 

Upon closing her eyes she sees pictures and all sorts of 
strange sights: Pulsatilla. 



CAUSES OF SUDDEN DEATH. 599 



CHAPTEE III. 

The Puerperal Diseases.— (Continued.) 

Causes of Sudden Death During Labor and the Puerperal 
State. — Death sometimes occurs suddenly during labor and in 
the puerperal state, and may be attributed to a variety of causes, 
among which the following stand most prominent: 

Pulmonary Thrombosis and Embolism.— It is claimed that 
the blood of a puerperal patient is in a hyperinotic state, and to 
that condition is ascribed the strong disposition to coagulation 
which has been observed. "In all the accidents and anxieties 
of obstetric practice," says Meadows,* "none can compare with 
the shock of the sudden death due to pulmonary thrombosis. A 
patient, apparently convalescing happily, is struck down with 
scarcely a moment's warning." This accident is sometimes due 
to detachment of vegetations from the cardiac valves, but of- 
tener, as has been intimated, to a general blood dyscrasia, which 
predisposes to coagulation. A clot may form on the right side 
of the heart, and extend to the pulmonary artery, the coagula- 
tion, it is said, taking place suddenly. The patient appears to 
be doing well, when upon making some exertion, it may be but 
raising the head, profound dyspnoea is suddenly developed, ac- 
companied by most frantic efforts to breathe, and faint cries, 
soon followed by syncope and death. It is liable to occur not 
only during the period immediately succeeding delivery, but 
even after the woman has begun to walk about. 

It is plain that but little room is given for treatment in such 

* " Manual of Midwifery," 4th Am. Ed., p. 447. 



600 THE PUERPERAL DISEASES. 

cases, and about all that can be done is to keep the patient as 
quiet as possible, and, if life is prolonged, with chance for re- 
covery, stimulants may be carefully exhibited. 

Syncope. — After excessive loss of blood, the heart, under the 
strain of some exertion, is liable to utterly fail. In such cases 
death takes place almost instantaneously. For days, and in ex- 
traordinary cases, for weeks subsequently to delivery, it is ad- 
visable to keep women who have suffered from exhausting hem- 
morrhages under the greatest restraint, as a very slight exertion 
is in some instances fatal. 

Whenever a woman faints in the puerperal state, it is highly 
important that she be revived as speedily as possible, for there 
is here a double danger— that of utter cardiac failure, and that 
of the retardation of the circulatory currents giving rise to co- 
agulation of blood, and the occurrence of fatal thrombosis or 
embolism. We should indulge in the free use of diffusible 
stimulants, and the immediate application of a sinapism to the 
precordial region. After being revived, the patient may have a 
few doses of veratrum album, or china, and subsequently such 
other remedies as appear to be indicated by the peculiar symp- 
toms presented. 

Death from the Entrance of Air Into the Yeins. — Mc- 
Clintock cites six cases in which death appeared to be due to 
the entrance of air into the veins. Madame Lachapelle men- 
tions two, and others have been reported. When firm uterine 
contractions do not follow delivery, the uterine sinuses are left 
in a condition favorable to the entrance of atmospheric air. In 
one of Madame Lachapelle's cases it was found that the "uter- 
ine sinuses opened into the interior of the uterus by large orifices 
through which air could readily be blown as far as the iliac 
veins, and vice versa." The very action of the uterus itself in 
contracting and expanding, would have a tendency to draw air 
into the sinuses, since at the moment of expansion, relaxation of 
the vessels, and the entrance of a certain amount of air into the 
uterine cavity are coincident occurrences. 

Pathologists are not in accord with regard to the cause of 
death in these cases. The most recent theory is that of Vir- 
chow, Oppolzer and Feltz, which refers the fatal result to im- 
paction of the air globules in the lesser divisions of the pul- 



DEFECTIVE LACTEAL SECRETION. 601 

raonary arteries, where they constitute gaseous emboli, and pro- 
duce death in the same manner as the fibrinous emboli. To 
this cause we may probably justly refer a considerable propor- 
tion of all cases in which sudden death occurs soon after de- 
livery. The symptoms do not correspond to those of shock as 
ordinarily manifested. 

Defective Lacteal Secretion. — Many women, especially 
those who possess a nervous temperament and are poorly nour- 
ished, are annoyed by having an insufficient quantity of milk to 
supply their babes. We believe the practice adopted by some 
physicians, who recommend the use of alcoholic stimulants in 
some form, is pernicious to both mother and child. Outside of 
the suitable homoeopathic remedy, our main reliance in such 
cases must be a sufficiency of good nutritious food, especially 
such as. contains phosphatic elements. Yet such mothers should 
never eat to repletion under the stimulus of a desire to provide 
nourishment for their young, as the result of such a practice is 
almost sure to be an unpleasant one. An article of food which 
in our experience has proved the most satisfactory, is fresh 
milk. Women of delicate nervous organization will sometimes 
thrive on it, while at the same time their supply of milk is 
greatly augmented. In exceptional cases it does not agree. 

The remedies most useful to increase the lacteal secretion are 
as follows: 

Scanty secretion, with despairing sadness: agnus cast 

Deficiency of milk, with over-sensitiveness: asafcetida. 

Scanty secretion of milk: bryonia.. 

Scanty secretion of milk in women of a scrofulous diathesis: 
calcarea carb. 

Mammae distended, but milk scanty: calcarea carb. 

Little milk, in mild tearful women in apparent health : Pul- 
satilla. 

Milk scanty or vitiated; child refuses it: mercurius. 

Scanty milk, with debility and great apathy : phos. ac. 

Lack of milk, with much stinging in the mammae: secale. 

Insufficiency, or entire lack of milk after parturition: urtica 
urens. 

Depressed Nipples. — When the nipples, instead of being 
prominent and full, are depressed, or retracted, the child expe- 



602 THE PUERPERAL DISEASES. 

riences the utmost difficulty in nursing, and on this account 
may, after a time, utterly reject the breast. 

In some of these cases the depression is due to anatomical de- 
fects, and cannot be overcome; but in others it is the result of 
pressure, and by manipulation and suction it is soon sufficiently 
overcome for functional purposes. If the defect cannot be 
remedied, a glass nipple shield, with rubber tube, will often af- 
ford a satisfactory medium through which the child may nurse. 

Excessive Lacteal Secretion. — This is known as galactor- 
rhea, and sometimes seriously interferes with successful lacta- 
tion. It is not alone women of robust constitution who are the 
subjects of excessive secretion of milk, but the weak and deli- 
cate as well, in whom, of course, it is a condition of greater im- 
port. In the former the secretion may be wholesome, but in 
the latter it is generally watery and innutritious, and, unless the 
morbid condition is corrected, serious effects upon the health are 
likely to be produced. The woman begins to suffer from weak- 
ness, emaciation, insomnia, headache, and a host of other un- 
pleasant symptoms, and is finally forced to relinquish nursing. 

Galactorrhea is in a measure under the control of remedies, 
and the effect of these should be tried before depriving the in- 
fant of the maternal breast. Those from which the greatest 
benefit is likely to be derived are, calcarea carb., uranium, Pul- 
satilla and pliytolacca. 

If the mother is unwilling to wean her child, certain remedies 
may be administered with salutary effect on her physical condi- 
tion. For the general weakness and prostration which she suf- 
fers, china, calcarea phos., phosphoric acid, and carbo veg. are 
the most useful. 

To correct the quality of the secretion, calcarea phos. may be 
given when it is watery. When the milk looks thin and blue, 
and the patient is sad and despairing on awaking,— lachesis. 
Milk impoverished, bluish, transparent, strong sour taste and 
odor, — deficient in casein: acetic ac. 

Sore Nipples.— In the early days of lactation, women are often 
tormented with erosions, excoriations, chaps, fissures and cracks 
of the nipple, giving rise in many cases to most intolerable suffer- 
ing. The trouble generally begins with simple erosion, but may go 
on from bad to worse, only to terminate in mammary abscess. 



SOKE NIPPLES. 603 

The affection is caused mainly by the friction of the child's 
month in nursing, and may be obviated by suitable care of the 
nipples both before labor and during lactation. Cazeaux re- 
gards the exposure of the nipples to cold, while warm and 
moist, as one of the most frequent causes of the trouble. When 
the soreness is developed subsequently to the tenth day after 
delivery, it is generally due either to biting by the child, or the 
communication to the nipples of an aphthous inflammation. 

When fissures have been formed, the irritation may be trans- 
mitted from the base of the nipples to the cellular tissue, "and 
eventually to the glandular structure itself. 

Treatment should be largely of a prophylactic nature. Dur- 
ing the latter months of pregnancy, the delicate skin, covering 
the nipple, may be hardened by the frequent application of 
astringent lotions, like strong tea and tannin. Such precautions 
are particularly appropriate to primipara3. When lactation be- 
gins, the nipples ought always to be sponged off with warm 
water after nursing, and gently dried, as the secretions of the 
child's mouth, if left, are capable of causing considerable irrita- 
tion. Should erosion be set up, and refuse to yield promptly to 
the measures adopted, the child should be made to nurse for a 
time through a shield. When cracks and fissures exist, it may 
be necessary in some cases to touch the raw surfaces once or 
twice with nitrate of silver. 

The following remedies when administered on the strength of 
the indications given, will in many cases, without the use of any 
adjuncts, be adequate to overcome the difficulty. 

Nipples itch, burn, look red: agaricus. 

Nipples sore from nursing : argenium nit 

Nipples ulcerated: calcarea carb. 

Nipples ache, and feel sore: calcarea phos. 

Nipples nearly ulcerated off, in neglected cases: castor equ. 

Nipples bleed much, and are very sore: lycopodium. 

Nipples feel very raw and sore: mercurius. 

Nipples ulcerate easily,and are very sore and tender: causficum. 

Nipples inflamed and very sensitive: chamomilla. 

Nipples dark, brownish red; unbearable pain on slightest 
touch; breasts full, skin hot, pulse strong: colchicum. 



604 THE PUEEPEEAL DISEASES. 

Nipples very sore to the touch; pain from nipple to scapula of 
same side whenever the child nurses: croion tig. 

Nipples painful, inflamed, cracked: graphites. 

Nipples very sensitive, will not bear contact with the clothing: 
helonias. 

Nipples sore, fissured, or covered with scurf; bleed easily: ly- 
copodium. 

Nipples itch, and have a mealy covering: petroleum. 

Nipples very sensitive: phytolacca. 

Nipples sore and fissured, with intense suffering on putting 
the child to the breast; pain seems to start from the nipple and 
radiate over the whole body: phytolacca. 

Nipples sore to touch, and sore and painful spot under right 
nipple: sanguinaria can. 

Nipples are sore, they itch and bleed: sepia. 

Nipples cracked across the crown: sepia. 

Nipples drawn in like a funnel: silicea. 

Nipples cracked, after nursing they burn and bleed: sulphur. 

Nipples painful during nursing, though there is but little ap- 
pearance of soreness: mix vom. 

Nipples in the first days of nursing feel sore as if bruised: 
arnica. 

Mastitis Pueepeealis. 

Structures Involved. — The inflammation which attacks the 
mammary gland in puerperal women, may involve either sepa- 
rate portions of the gland, the entire organ, the sub-mammary 
connective tissue, or the glands of the areola. When the paren- 
chyma of the gland is the seat of the morbid change, the inflam- 
mation generally originates in the walls of the lacteal ducts, in- 
vades the acini of the glands, and is apt to pass rapidly to the 
stage of suppuration. These abscesses usually open spontane- 
ously when left to themselves, and end in complete recovery. 
Sometimes, however, fistulous openings remain for a long time. 
Occasionally milk nodules are formed, being indurated portions 
of the gland constricted and rendered useless by the pressure of 
the hyperplastic connective tissue. Abscesses may become en- 
cysted, and the pus undergo fatty or calcareous change; or they 
may remain stationary for a time, but after a while give rise to 
severe inflammatory symptoms. When the sub-mammary con- 



MASTITIS PUEEPEEALIS. 605 

nective tissue is the seat of attack, the pus may burrow either 
outwards or inwards. The gland becomes prominent, and ap- 
pears to rest loosely on an elastic base. Much oedema is gen- 
erally observable. When the follicles of the areola are the struct- 
ures involved, they present furunculous appearances. 

Symptoms. — The first symptom which attracts attention when 
the parenchyma of the gland is involved, is a nodule, hard, ir- 
regular, tender, movable, and of variable size. The integument 
is at first unchanged in appearance, but soon becomes red. As 
the case proceeds, the nodule enlarges; the axillary glands swell; 
there is a chill, followed or accompanied by dull, piercing, or 
throbbing pain, also loss of appetite, sleeplessness, and head- 
ache. The integument gradually becomes prominent at some 
particular point, cedematous and purple; fluctuation is observed, 
and, if left to itself, the pus after a time, is discharged through 
one or more openings. Yelpeau once found fifty-two collections 
of pus in one mammary gland. Large cicatrices are often left. 
The symptoms generally abate after discharge of the pus, but 
in some cases they become more violent, and pysemic conditions 
may follow. When the inflammation is in the sub-mammary 
connective tissue, the pain is often extreme, and movement of 
the arm on the affected side rendered almost impossible. The 
resulting abscesses often attain great size. Inflammation here 
rarely undergoes resolution, but suppuration is the almost inva- 
riable result. 

Causes. — The causes of mammary inflammation may be traced 
to exposure to cold, a blow, or other injury of the breast; tem- 
porary engorgement of the lacteal tubes; strong mental emo- 
tions, or, more frequently than all else, to irritation from fis- 
sures or erosions of the nipples. In fifty lying-in women who 
were afflicted with mastitis, Winckel* found but one who had 
not suckled her child. The affection does not necessarily de- 
velop during the existence of the fissures and erosions resulting 
from nursing, but may appear from eight to fourteen days 
after their complete cicatrization, or even later. The inflamma- 
tion often creeps very slowly from the orifices of the lacteal 
ducts toward the periphery of the gland. The assertion that an 

* " Winckel, Pathology and Treatm. Childbed," Am. Ed., 1S76, p. 380. 



606 



THE PUEKPERAL DISEASES. 



* TVixckel, loc. cit. p. 381. 



obstruction to the flow of the milk is the most common cause of 
mastitis is absolutely incorrect.* 

Parenchymatous mastitis sometimes appears in the course of 
puerperal pyaemia, and has a depuratory effect. It may also de- 
velop in the interlobular cellular tissue in case of metrophle- 
bitis. 

Sub-mammary abscesses often develop spontaneously as a pri- 
mary affection, or secondarily on peritonitis, caries of the ribs, 
and perforation of a pleuritic effusion. 

Treatment. — When mastitis appears in the course of pyae- 
mia, attempts to arrest the process are not only useless, as a 
rule, but absolutely unwise. Suppuration should be hastened 
by the application of poultices, and the administration of hepar 
sulphur. As soon as there is a considerable accumulation of 
pus, the abscess ought to be evacuated. 

Treatment of parenchymatous mastitis, disconnected with 
pyaemia, should be entirely different. As soon as the first traces 
of inflammation are observed, energetic measures must be adopt- 
ed. The child should be put to the breast at longer intervals, 
and, if the inflammation increases, should be taken from it en- 
tirely; but nursing of the well gland may be continued. . Unless 
engorgement should become extreme (a thing which is not 
likely to occur), no efforts should be made to remove the secre- 
tion. By such treatment we admit that suppression of the milk 
is almost certain to result, but that consequence is far prefera- 
ble to mammary abscess. There need be no fear that, from 
neglect to draw the milk, congestion of the affected breast will 
be prolonged and unfortunate results be promoted. Rubbing of 
the breast should not be permitted. 

In the early stage of the affection, hot fomentations should 
constitute the main local treatment. Into the hot water should 
be put a small quantity of phytolacca tincture, and the cloths 
changed often enough to be kept hot. A good mode of applica- 
tion is to line a tin vessel of suitable size with the hot woolen 
cloths, and then invert it over the breast. The heat should be 
as great as can be borne, and it should be maintained most of 
the time until the pain and soreness disappear, or the process 



MASTITIS PUERPEKALIS. 607 

has gone beyond the point of possible arrest. Under the faith- 
ful, early use of these measures, together with the indicated 
remedy, mammary abscesses will not be frequent. 

When, in spite of all efforts to subdue it, the inflammatory ac- 
tion goes on, the general treatment should be much the same as 
that bestowed on any other large abscess, and the pus removed 
at the earliest practicable moment. In lancing a mammary ab- 
scess, the lowermost margin of the pus cavity should be selected 
as the site of the incision, and the opening should always be 
made parallel to the course of the lacteal tubes, so as not to 
sever any of them. Sub-mammary pus collections should be 
evacuated on the outer margin of the gland. 

This matter of lancing a mammary abscess, and subsequently 
caring for the breast until it has been restored to a healthy state, 
merits careful study. "The opening of the abscesses," says 
Billroth,* " should always be done with a knife, and there is no 
advantage in delay. Very great advantages are here derived 
from the antiseptic treatment. The breast is first cleaned with 
soap, then washed with a weak solution of carbolic acid, and an 
incision one centimeter long is to be made in the direction of 
the radius of the breast. The drainage tube is then inserted, 
the pus withdrawn, the breast again bathed with the carbolic 
acid lotion, and the breast compressed from all sides with anti- 
septic gauze. 

" If the antiseptic precautions are fully carried out, one will 
never see such cases as were common heretofore, in which the 
breasts were undermined for months with abscesses, and the 
woman suffered untold misery." 

Firm and equable compression should subsequently be exert- 
ed by means of a bandage well applied. One which does not 
exert uniform pressure is worse than none, and hence the neces- 
sity for the greatest care. Some have recommended that each 
turn over the breast be made fast and firm by the use of plaster 
of Paris, the incision alone being left uncovered. The bandage 
should be changed as often as seems necessary. Some prefer 
the use of strips of adhesive plaster. Adhesive plasters are 
now made purposely for such cases, and, when properly applied, 
serve a very good purpose. Painting the breast with a thick 

* " Handbuch der FrauenfcrankheiU'ii.*' 



608 THE PUERPERAL DISEASES. 

layer of collodion immediately after lancing is a favorite method 
with some. 

Our remedies have also a decided influence over this painful 
affection, but they require to be chosen with great care. 

Excessive Secretion. — Breasts greatly and painfully distended 
with milk; abscess threatened: acetic acid. 

Secretion of milk too abundant: calcarea carb., uranium, 
Pulsatilla, phytolacca. 

Pains, Etc., in Mammce. — Burning in the breasts: actcea 
racemosa. 

Constrictive pains in the left mamma when the child nurses 
the right: borax. 

Griping, and sometimes stitches in the left mamma, and 
when the child has nursed she is obliged to compress the breast 
with the hand, because it aches from being empty : borax. 

Stitches as from needles in the left breast: conium. 

Cutting in left mamma through to scapula; sighing, short 
breath: lilium. 

Cramp-like pain in left mamma, shoulder and fingers : lilium. 

Burning, stinging pains: apis. 

Burning pains; relief from motion: arsenicum. 

Tensive burning and tearing pain: bryonia. 

Pains and burning: calcarea phos. 

Darting pains of nursing women; they arrest breathing, and 
are worse from pressure: carbo an. 

Stitches in the breasts: creosotum, sanguinaria. 

Induration, Inflammation, Suppuration, Etc. — Left 
Mammal. — Lumps deep in left breast; aching pains: arum try. 

Left breast inflamed, suppurating, with a feeling of fullness 
in the chest; sensitive to cold air; scrofulous: cistus. 

Either — Both Mammce. — Burning, stinging, swelling, hard- 
ness, even suppuration: apis. 

Breasts feel heavy, are pale, but hard and painful: bryonia. 

Inflammation; sensation of fullness in the chest, over-sensi- 
tiveness to cold air: cactus. 

Mammae sore to the touch: calcarea phos. 

Suppuration; fine stinging in the nipples: camphora. 

Hard, painful spots: carbo an, phytolacca. 

Swollen, inflamed (erysipelatous): carbo an. 



MASTITIS PUEEPEKALIS. 609 

Hard and tender to the touch; with drawing pains : chamomilla. 

Induration and inflammation: cistus. 

Hard and swollen, with pain from nipple to scapula: croton 
tig. 

Swelling and induration: cuprum met. 

Bluish, with blackish streaks, lancinating pains in the breast 
and down the arm: lachesis. 

Suppuration of the mammae: stdphur, hepar sulphur, mercu- 
rius, silicea, pkytolacca. 

Swollen, hard, with sore pains; nipples ulcerated: mercurius. 

Hard, red spots or streaks; fistulous openings, with burning, 
stinging, and watery, offensive discharge: phosphorus. 

Inflammation, swelling, suppuration: phytolacca. 

"Broken breasts," with large, fistulous, gaping, and angry- 
openings discharging a watery, fetid pus : phytolacca. 

"Caked breast:" phytolacca. 

Swollen breasts ; rheumatic pains extend to the muscles of the 
chest, shoulders, neck, axillae and arms ; pains change from place 
to place: pulsatilla, aetata rac. 

Breasts swell from catching cold, especially from getting wet; 
streaks of inflammation; milk vanishes, with general heat: rhus 
tox. 

Suppuration; chilliness in forenoon; heat in afternoon: 
sulphur. 

Soreness of the follicles within the areola: calendula (topi- 
cally.) 

Chilly crawls over the mammae; guajacum. 

Chilliness over the mammae: cocculus. 

Herpes of the breasts: dulcamara. 



610 THE PUERPERAL DISEASES. 



CHAPTEE IY. 

The Puerperal Diseases.— (Continued.) 

Puerperal Eclampsia. — This term is used to designate con- 
vulsions associated with, and directly or indirectly growing out 
of pregnancy, parturition, and the puerperal state, characterized 
by unconsciousness, followed by coma. Convulsions due to 
hysteria, true epilepsy, and cerebral lesions, since their connec- 
tion with the physical states above mentioned is merely acci- 
dental, are not intended to be here included. 

Eclampsia is fortunately a rare event, occurring but about 
once in five hundred cases. It is met more frequently in primip- 
arse than in multipara, especially in elderly primiparse, in twin 
pregnancy, in women with contracted pelves, and in connection 
with the birth of male children. It is sometimes epidemic. 

Etiology. — The causes of eclampsia are still matters of dis- 
pute, which fact, in a measure, accounts for the comparatively 
ill success attending its treatment by physicians of all schools 
of medicine. Many theories have been advanced, but that one 
which attributes the manifestations to the retention in the sys- 
tem of certain effete matters, is the one which has met with most 
general acceptance. The existence of albumen in the urine of 
women suffering from eclampsia was first observed by Dr. John 
C. W. Lever, in 1842. Frerichs, in 1851, called attention to the 
close resemblance between the convulsions occurring in preg- 
nancy, and the uraemic convulsions of Bright' s disease, and drew 
the conclusion that "true eclampsia occurs only in pregnant 
women suffering with Bright's disease." This view was soon 
after supported by Braun and Wieger, and has come down, with 
slight modification, to the present time. 



ECLAMPSIA. 611 

With regard to the presence or absence of albumen, it should 
be remembered that no one can doubt that its presence is far from 
being a constant symptom of eclampsia; but this is compara- 
tively unimportant, since the claim of most of those who sup- 
port the uraemic theory is that the uraemia and convulsions are 
not due to the presence or absence of albumen, but to the ex- 
istence of renal insufficiency. 

It is not uniformly held by later authorities that the renal in- 
sufficiency is, in every instance, due to Bright' s disease, for the 
results of autopsies do not justify such a conclusion. The real 
nature of the circulatory changes is not known, but some believe 
that either the walls of the vessels are altered in such a manner 
as to interfere with the process of diffusion, or that the calibre 
of the vessels is reduced from reflex action set up by peripheral 
stimulus. Color is given the latter theory by Frankenhaeuser's 
discovery of a direct connection, by means of the sympathetic 
nerve, between the ganglia of the kidneys and the nerve fila- 
ments of the uterus. 

Frerichs believed he had found the secret of the outbreak of 
convulsions in his theory of the development of carbonate of 
ammonia in the blood from the retained urea; but later research 
has led to the conclusion that " ammoniaeniia is to be regarded 
as one of the rarest causes of convulsions." 

According to the Traube-Rosenstein theory, eclampsia takes 
place in women rendered hydraemic by the loss of albumen, and 
in whom sudden increase of the aortic pressure gives rise, first 
to cerebral oedema, then secondary compression of the vessels, 
and, finally, to acute anaemia. This theory is entertained by 
many, but is rejected by others. 

From a thorough consideration of the phenomena presented, 
and the various theories which have, from time to time, been ad- 
vanced, it seems probable that, in the greater share of cases, 
uraemia is the condition upon which convulsibility depends. 
This may be due in one case to organic changes in the renal or- 
gans, and in another to functional disturbance of their circula- 
tion. Still, all uraemic patients do not suffei from eclampsia; 
and the efficient causes of the paroxysms are probably various. 
The possibility, and indeed probability, of eclampsia being oc- 
casionally provoked by peripheral irritation, should not be over- 



612 THE PUEEPEEAL DISEASES. 

looked. It appears quite possible that, in susceptible subjects, 
an attack may be brought about through such a cause, without 
the co-existence of uraemia, while in ursemic patients, peripheral 
irritation probably acts as a common exciting cause of the 
seizures. 

Symptoms. — The symptoms of individual cases of eclampsia 
are remarkably similar, differing chiefly in the intensity and du- 
ration of their manifestations. Distinct precursory symptoms 
precede the actual appearance of eclamptic convulsions in about 
thirty per cent, of all cases, consisting of headaches, nausea, diz- 
ziness, muscce volitantes, amblyopia, even amaurosis, pain in the 
epigastrium, muscular tremor, mental depression or excitement, 
laughing or crying, talkativeness, insomnia, etc. Such symptoms 
usually last only a short time ; but may continue for several 
days. In the majority of cases the attack suddenly sets in with 
a loud cry, or the patient begins convulsive movements of some 
part of the body, it may be an arm, and then another part 
becomes implicated, until finally all the extremities are involved. 
The arms and legs are violently twitched, or swung about, the 
eyes, with dilated or contracted pupils, roll spasmodically, and 
are not affected by light; the face is livid; the respiration is at 
first panting, and then entirely arrested for a time, after which 
it may be stertorous. There is foam at the mouth; the teeth are 
gnashed; the tongue is bitten; the pulse is rapid; and the tem- 
perature rises. 

In the interval between seizures, the pulse slackens its pace, 
and becomes fuller; while the respiration gets regular, but con- 
tinues more or less stertorous. From this condition the patient, 
after a time, arouses, but remains more or less dull or confused. 

The number and frequency of the attacks vary greatly. 
There may be but a single seizure, or the paroxysms may num- 
ber twenty-five or thirty. Winckel says * that the greatest num- 
ber he ever witnessed in a case which terminated in recovery, 
was seventeen. 

Death sometimes takes place during an attack; and again it 
often occurs in the comatose stage from pulmonary oedema and 
cerebral apoplexy. When recovery ensues, as it does in the 

*Winckel, " Pathology and Treatment of Child-bed," Am. Ed.. 1876, p. 440. 



ECLAMPSIA. 613 

majority of cases, there is a decrease in the frequency, duration, 
and intensity of the paroxysms, followed by a deep, quiet sleep. 

Diagnosis. — Diagnosis of true eclampsia is not always easily 
made. We are obliged to form our opinions many times by the 
method of exclusion. To this end, therefore, we should en- 
deavor to learn whether the woman is subject to epileptic attacks, 
or convulsions which are epileptiform in character. With re- 
gard to the symptoms of the paroxysms of puerperal eclampsia 
and epilepsy, it should be known that they are not characterized 
by widely different phenomena, and differentiation is exceedingly 
difficult. The intensity of the comatose stage is said to be 
greater in eclampsia than in epilepsy. In hysterical convulsions 
the consciousness is not generally lost, the attacks are less vio- 
lent, there is no comatose stage, and the patients weep, scream, 
or laugh in the midst of the paroxysm. 

Prognosis. — The prognosis is always serious, and more so 
when the eclampsia precedes delivery. The relative results of 
homoeopathic and old-school practice cannot be stated, but they 
would seem to be decidedly in favor of the former. Under the 
latter, however, the percentage of recoveries has greatly in- 
creased since the abandonment of repeated and indiscriminate 
bleeding. The results of eclampsia must be held to vary ac- 
cording to the severity, frequency, duration and number of the 
paroxysms. 

Braun says he has never known but one patient to recover 
when attacked between the fourth and sixth months of preg- 
nancy, except where abortion has taken place. 

When several seizures are suffered, the life of the child is 
nearly always destroyed. 

Treatment. — Treatment of eclampsia may be very aptly con^ 
sidered under the two heads, preventive and curative. 

Preventive Treatment. — Whenever prodromi are observed, all 
exciting causes of convulsions should be removed, and tlie 
patient's surroundings made as pleasant and sanitary as possi- 
ble. Symptoms which will require special attention have been 
considered by themselves in other places, and the most valuable 
remedies for them indicated. Among these symptoms we may 
mention insomnia, cephalalgia, and albuminuria. 



614 THE PUERPERAL DISEASES. 

Curative treatment will be more or less modified by the period 
at which the convulsions are developed. 

When eclampsia sets in during pregnancy, and the paroxysms 
are not brought under control, the question of inducing labor 
has to be settled. The advisability of such an operation is ad- 
vocated by some, and denied by others, and will have to be con- 
sidered and settled in individual cases as they arise. It cer- 
tainly ought not to be undertaken without other measures have 
utterly failed, as the favorable effects of the operation have not 
been conspicuous. 

In a large percentage of instances uterine action is excited by 
the convulsions, and dilatation of the os uteri begins, by which 
the case practically resolves itself into one of eclampsia during 
labor, and should be managed accordingly. 

Convulsions which occur after labor has begun have a ten- 
dency to recur until the completion of the parturient act, and 
then to cease. It is therefore advisable to hasten the delivery 
by every obstetrical resource which is not inimical to the 
woman's safety. These in the first stage consist in rupturing 
the membranes, catheterizing the uterus, and employing manual 
dilatation; and, in the second stage, the using of the forceps. 

"At the recurrence of the fit," says Dr. Ludlam,* "a thick 
piece of india rubber, or of soft wood, should be placed between 
the teeth, in order to protect the patient's tongue. She should 
not be held forcibly or firmly to the bed, but simply prevented 
from throwing herself upon the floor or otherwise inflicting bod- 
ily injury. Too much constraint might increase the difficulty, 
and would do no good. If she has an antipathy to the nurse, 
the husband, or any one in the room, you had better send them 
out. And do not let bystanders give vent in her hearing to ex- 
clamations of fright and horror at the contortions of which they 
are witnesses." 

Therapeutical Resources.— " No remedy," justly remarks 
B8ehr,t " responds to this disorder as completely as belladonna." 
The indications for its use, according to Guernsey, are as fol- 
lows: She has the appearance of being stunned; a semi-con- 
sciousness and loss of speech; convulsive movements in the 

* "Diseases of Women," Fourth Edition, p. 260. 
t " The Science of Therapeutics," p. 166. 



ECLAMPSIA. 615 

limbs, and muscles of the face; paralysis of the right side of the 
tongue; difficult deglutition; dilated pupils; red or livid coun- 
tenance. She may have paleness and coldness of the face, with 
shivering; fixed or convulsive eyes; foam at the mouth; invol- 
untary escape of the foeces and urine; renewal of the fits at 
every pain; more or less tossing between the spasms; or deep 
sleep, with grimaces; or starts and cries with fearful visions. 
The efficacy of belladonna has been repeatedly demonstrated. 

Gelsemium has proved to be a remedy of remarkable value in 
this disorder. It is indicated in attacks brought on by periphe- 
ral irritation as well as those occasioned by ursemia. One of 
its prominent symptoms, sometimes observed as premonitory of 
eclampsia, is a large feeling of the head. The pulse is full, but 
not hard. We incline to the use of the tincture in doses of sev- 
eral drops, a number of times repeated, if necessary. 

Veratrum viride makes up the trio of remedies which are of 
greatest service in the treatment of eclampsia. Its particular 
indication is high arterial tension, or circulatory excitement 
To get the desired effect, it should also be used low, and in ap- 
preciable doses. 

Following are indications for other remedies: Seizures pre- 
ceded by restlessness, and a sensation of general expansion, 
mostly of face and head: argentum nit. 

Convulsions following difficult labor, and those which appear 
to be brought on by changing position: cocculus. 

Spasms during parturition, with violent vomiting, or with every 
paroxysm opisthotonos, spreading of the limbs and opening of 
the mouth: cuprum met. 

Convulsions during pregnancy, of a clonic nature, beginning 
in one part, and spreading: cuprum met. 

Unconsciousness; face bright red, puffed; full, hard pulse; 
urine copious and albuminous: glonoinum. 

Convulsions, with urine scanty, dark, floating dark specks, or 
albuminous : helleborus. 

Convulsions, shrieks, anguish, chest oppressed; unconscious- 
ness : hyoscyamus. 

Convulsions during and after labor; drowsiness, open mouth, 
coma between paroxysms: opium. 

Convulsions following sluggish or irregular labor pains; un- 



616 THE PUERPERAL DISEASES. 

conscious; cold, clammy, pale face; stertorous breathing, full 
pulse: Pulsatilla, 

Labor ceases and convulsions begin: secale. 

Convulsions with opisthotonos: secale. 

Convulsions with copious sweat: stramonium. 

Convulsions, with jerking of every muscle in the body, includ- 
ing eyes, eyelids and face : hyoscyamus. 

Convulsive twitches, especially after fright or grief: ignatia, 
gelsemium, opium. 

Stertorous respiration continues from one spasm to another: 
opium. 

Bright light, or contact, renews the spasms: stramonium. 

Extreme degree of nervous erethism : coffea, stramonium. 

Excessive nervous sensibility: asarum. 

For the insomnia which precedes eclampsia: coffea, aetata 
caulophyllum, hyoscyamus. 

Awakens with a shrinking look as if afraid of the first object 
seen: stramonium, 

We do not feel that our description of remedial measures is 
what it ought to be, without allusion being made to other reme- 
dies, which, however, we cannot recommend for adoption until 
those homceopathically indicated have failed to afford the neces- 
sary relief. 

Chloroform is regarded as of the greatest value in certain 
cases, while in others, its influence has not proved beneficial. 
Its administration should be carried to the point of complete 
narcosis, but its action ought not to be very long sustained. 

Opium and Morphia. — These narcotics have been highly praised 
for their effect in eclampsia. The former should be given by the 
mouth, and the latter by hypodermic injection. Doses of double 
the ordinary size may be employed. This mode of treatment 
has received very strong endorsement from old-school author- 
ities. 

Apocynum can., by hypodermic injection of the fluid extract, 
has been employed with excellent effect in true eclampsia by Dr. 
C. S. Fahnestock.* 

Chloral hydrate in doses of twenty grains, repeated several 

*"Tlie Clinique," toL i, p. 321. 



PUERPERAL FEVER. 617 

times within twenty-four hours, if necessary, in some cases also 
controls the paroxysms. 



CHAPTEE Y. 

The Puerperal Diseases.— (Continued.) 

Puerperal Fever, (Puerperal Septicaemia, Sapr&mia, 
Puerperal Pyaemia.) — "The man of positive opinions on all 
subjects is to be envied," says Glisan,* "because of the com- 
fortable assurance that a firm belief or disbelief in any doctrine 
affords him. But when among a number of learned and experi- 
enced clinical observers in diseases of women some state that 
puerperal or child-bed fever is essentially a zymotic disease pe- 
culiar to puerperal women, as specific in its nature as typhoid 
or typhus fever, or small-pox, and bears the same relations to 
local concomitant pathological conditions as the ulcers in the soli- 
tary glands and glands of Peyer do to typhoid fever, or the pus- 
tules on the skin to small-pox; while others affirm that the 
disease is essentially a local inflammation like phlebitis, perito- 
nitis, metritis, or lymphangitis, producing constitutional effects 
of a secondary character; others again, that the malady is only a 
form of pyaemia or septicaemia, modified somewhat by the puer- 
peral condition of the patient; we must consider the nature of 
puerperal fever as undetermined. The local inflammation theo- 
rists are divided among themselves as to the seat of the inflam- 
mation, and have been contending against each other so vehe- 
mently, that from this cause, and the pressure from without, 
their hypotheses are fast declining in popularity. Latterly the 
contention is chiefly conducted between the zymotic and septi- 
cemic theories." 

Lusk says:f " It has now passed the domain of dispute that 
puerperal fever is an infectious disease, due, as a rule, to the 

* " Text-Book of Modern Midwifery," p. 618. 
f" Science and Art of Midwifery," p. 608. 



618 THE PUERPERAL DISEASES. 

septic inoculation of the wounds which result from the separa- 
tion of the decidua and the passage of the child through the 
genital canal in the act of parturition." The statistical frequency 
of septic puerperal diseases is due doubtless to the length of the 
parturient canal, and the extensive area, denuded in many places, 
over which the physiological excretions must pass in their escape, 
as well as with which the fingers and instruments are brought in 
contact during labor. 

The greater number of modern observers entertain the convic- 
tion that the infectious diseases of the puerperal state are of 
septic origin; and the question of the identity of puerperal fever 
and septicaemia or pyaemia has become one mainly of definition. 

Pathological Anatomy. — The anatomical lesions with which 
puerperal fever is associated are various, and the inflammatory 
processes observed are rarely limited to a single tissue. The 
following classification of lesions by Spiegelberg,* will be found 
of the greatest utility. 

1. Inflammation of the Genital Mucous Membrane. — Endo- 
colpitis and endometritis. 

a. Superficial. 

b. Ulcerative (diphtheritic.) 

2. Inflammation of the Uterine Parenchyma, and of the Sub- 
serous and Pelvic Cellular Tissue. 

a. Exudation circumscribed. 

b. Phlegmonous, diffused, with lymphangitis and pyaemia ( lym- 
phatic form of peritonitis). 

3. Inflammation of the Peritoneum covering the Uterus and 
its Appendages. — Pelvic peritonitis and diffused peritonitis. 

4. Phlebitis Uterina and Para-uterina with formation of 
thrombi, embolism, and pyaemia. 

5. Pure Septicaemia. —Putrid absorption. 

Endocolpitis and Endometritis. — The passage of the foetus 
through the parturient canal nearly always results in lacerations 
more or less extensive of some of the soft tissues, the most com- 
mon situations of which are the os uteri and vulva. After deliv- 
ery it often happens that the edges of these wounds begin to 
ulcerate, giving rise to what has been called the "puerperal 

* " Ueber das Wesen des Puerperalfiebers," Volkmann's " Samml. Klin. 
Yortr.," No. 3. 



PUERPERAL FEVER. 619 

ulcer." A frequent location of ulceration is on the surface of a 
ruptured perineum or frenulum, though ulcers are occasionally 
found in the vagina when the perineal laceration has healed by 
first intention. These " puerperal ulcers," in advanced stages 
are found to be covered with a brownish-green layer, and are 
usually associated with cedematous swelling of the labia. In 
favorable cases, under judicious treatment the deposit clears 
away, and repair takes place by granulation. 

The ulcers sometimes present diphtheritic appearances, and 
extend along the surface of the vaginal mucous membrane, or 
even down the thighs, accompanied with more or less oedema. 
The mucous membrane of the vagina feels soft and infiltrated, 
and being similar to erysipelatous inflammation in the skin, has 
been termed by Yirchow, erysipelas malignum puerperale in- 
iernum. 

Extension of the process involves the uterine mucous mem- 
brane, and, when intense, the inner surface of the uterus has the 
appearance of severe catarrhal inflammation. Mortification 
may ensue, in which case the condition takes on a diphtheritic 
character. The superficial layers mortify in patches, and between 
the normal mucous membrane yellowish-brown places are seen, 
from which masses of detritus can easily be scraped. In those 
cases wherein the entire endometrium becomes involved, there 
will everywhere be found, according to the state of the serous 
transudation into the organ, either brownish particles or a 
smeary, chocolate-colored mass, after the removal of which the 
deeper layers of the mucous membrane, or the muscular fibres 
themselves, are exposed. The placental site also participates in 
the changes. 

The uterus itself becomes more or less involved, and it is 
found either only slightly contracted, or its whole substance 
cedematous. In bad cases the lymphatics are distended with 
purulent matter, the origin of which condition is sometimes 
traceable to the unhealthy ulcers of the cervix. 

The inflammation does not usually extend to the mucous 
membrane of the Fallopian tubes. Purulent salpingitis occa- 
sionally takes place, and either by extension of the inflamma- 
tion or by rupture of the tube, peritonitis is excited. 

Metritis and Parametritis. — (Pelvic Cellulitis) — When the 



620 THE PUERPERAL DISEASES. 

endometritis becomes intense, the parenchyma of the organ gen- 
erally shares in the morbid processes. This is manifested by 
oedema, imperfect contraction, and a remarkable softness of the 
tissues. When the endometritis extends deeply, putrescentia 
uteri is quite apt to result, and lead to perforation of the uterine 
walls, thereby opening up the abdominal cavity. 

From the connective tissue surrounding the vagina, or that 
covering the uterus, the inflammatory process may extend be- 
tween the folds of the broad ligament, and thence ascend to the 
iliac fossa. One side only is usually affected. From the iliac 
fossa, the inflammation spreads in different directions, but rarely 
extends forward around the bladder. 

In mild, uncomplicated cases, the process always terminates 
in recovery, and the oedema speedily vanishes. Where the cell- 
elements do not accumulate to any great extent, hardly a trace 
of the disorder is left behind; but in other cases a hard tumor 
remains, consisting of finely granular detritus, which may disap- 
pear in a few weeks. 

More intense infection is liable to result in necrotic softening 
of the subserous connective tissue, and the formation of a pu- 
trid abscess. In many cases of parametritis, thrombosis of the 
lymphatic vessels is found within the inflamed spot, which con- 
dition Yirchow has shown to be in some degree a favorable in- 
cident, since the occluded vessels are prevented from carrying 
the infectious substances, and the extension of the morbid 
changes is thereby limited. 

By extension, the ovaries also become implicated in the in- 
flammatory action; but ovarian abscesses thus originating are 
extremely rare. 

Peritonitis. — Pelvic peritonitis may be said to consist, in 
general, only in an inflammatory irritation of the serous mem- 
brane, attended with but little exudation. Sometimes pseudo- 
membranes are formed, resulting in adhesions between the con- 
tiguous surfaces of the pelvic organs; and when this occurs, 
cicatricial shrinkage may cause a change in the position of the 
organs, and create a variety of complaints. When the inflam- 
mation is intense, suppuration may ensue, and the pus, when 
encapsuled, is slowly absorbed. Pelvic peritonitis is liable, by 
extension, to involve the whole serous membrane. 



PUERPERAL FEVER. 621 

General peritonitis does not often follow endometritis; but 
arises most frequently in the course of parametritis or pelvic 
peritonitis, in the following manner: If the swelling in case of 
parametritis is great, the dragging upon, and changes in the 
position of the peritoneum cause an irritation which eventuates 
in perimetritis, or pelvic peritonitis, which condition, in fatal 
cases, rapidly extends, and general peritonitis soon follows. 

In relatively mild cases the peritoneum, and especially that 
part of it which invests the intestines, is finely injected, and a 
loose pseudo-membrane is formed, which, in recent cases, unites 
the abdominal organs more or less firmly. The exudation is 
sometimes very moderate in quantity and free from pus cells; 
while in other cases patches of pus, and thick membranes of co- 
agulated fibrin are found. The liver and uterus generally have 
a thick coating; the intestines are distended, and the diaphragm 
is pushed upwards. 

In the worst cases the exudation is not fibrinous, but brown- 
ish and putrid in character, and the intestines have a dark, 
brownish red appearance. They are always fatal. 

Phlebitis Uterina and Para-uterina. — Inflammation is apt 
to be set up in those veins which traverse tissues in or near the 
uterus which are infiltrated with purulent or septic matters. As 
a result, the endothelium undergoes proliferation, and throm- 
bosis is produced. A normal thrombus is in itself harmless, 
and may in time become organized; but when pus or septic mat- 
ters obtain access to it, disintegration ensues, and the particles 
are swept into the circulation. Wherever such emboli happen 
to lodge, inflammation is aroused, and abscesses result. The 
thrombi sometimes extend, by accretion, toward the heart, 
stretching from the uterus through the spermatic, hypogastric, 
and common iliac veins, to the vena cava. Such a formation is 
sometimes traceable back to the placental site. 

Pure Septicaemia.— By this term we designate a condition 
arising in woman during the puerperal state, from the absorp- 
tion into the system of septic matter, or organic material in the 
process of decomposition. It probably differs in no essential 
particular from surgical septicaemia, and the local pathological 
conditions which have been described are among its effects. 
Local inflammation does not always arise from extension of the 



622 THE PUERPERAL DISEASES. 

process through continuity of tissue, but the inflammation of more 
distant tissues and organs is created in the same way as in in- 
fection after injuries of other parts of the body, and as in sur- 
gical diseases. 

When the sepsis is intense, death sometimes rapidly ensues, 
and the autopsy discloses to the unaided eye only a dark and 
non-coagulable state of the blood, with ecchymoses of the va- 
rious tissues, and under the microscope is seen fine, granular 
infiltration, fatty degeneration, or cell disintegration. 

When the infection is not so intense, the vital organs are not 
so powerfully assailed, and elevated temperature is almost the 
sole indication of general disturbance." In the absence of fur- 
ther supply of septic matter, these symptoms rapidly disappear; 
but when the poisonous matter continues to be absorbed in small 
quantities, the fever is sustained, and inflammations of other 
organs are likely to ensue. 

We shall not attempt a description of all the pathological 
changes revealed in the post-mortem examination of women 
dead from septicaemia following the course alluded to, and the 
symptoms of which merge into those of pyaemia. It has been 
suggested that the blood in these cases becomes so altered by 
the infection, and loaded with septic matter, that it is capable 
itself of exciting inflammatory action wherever it may circulate. 
It has been observed that in some epidemics, the serous mem- 
branes, in others the mucous membranes, in others, again, the 
veins, and in still others the lymphatics, become prominently 
affected. Abscesses may form in various organs and tissues as 
the result of pyaemic processes. 

When the peritoneum has been inflamed, it is found more or 
less extensively congested, spread over with lymph, and the in- 
testines and abdominal organs adherent to one another. In the 
cavity will be found serum, sometimes clear, but at other times 
mixed with lymph, pus, and blood. Similar changes, after in- 
flammation, are found in the pericardium and pleura. Endom- 
etritis is rarely secondary on general septic infection, and the 
anatomico-pathological changes arising from local causes, have 
been sufficiently described. Infection of the veins and lym- 
phatics also usually arises from direct extension of the inflam- 
matory process. 



PUERPERAL FEVEK. 623 

Cliannels of Absorption.— The inner surface of the uterus, 
especially at the placental site, as well as the vaginal and vulvar 
surfaces in all puerperal women, affords most eligible absorbent 
areas, and that through these septic matters reach the system, 
has been clearly demonstrated. There is reason to believe that 
infection may, in certain cases, result from absorption of septic 
• matter through the mucous membrane of the. vagina and cervix 
without there being any breach of surface. 

Granulating surfaces are not absorbing surfaces, and hence it 
follows that infection usually takes place, if at all, before repair 
has fairly begun. 

The character and sources of the septic matter constitute a 
question which has been variously answered, but not fully set- 
tled. It is clear that in some cases the infection is from within, 
and hence (Mitogenetic, while in others it is from without, and 
therefore heterogenetic. 

Antogenetic Sepsis. — Auto-infection may arise from any 
condition with which is associated decomposition, either of the 
tissues of the woman herself, of the foetus or of any other re- 
tained part of the product of conception. As examples of these 
we may mention the sloughs of maternal tissue which result 
from long-continued pressure, and retained portions of placenta, 
or even of membranes. That infection frequently arises from 
such sources is beyond question, and that it does not often occur 
must be explained mainly on the ground of early granulation of 
denuded surfaces. 

Heterogenetic Sepsis. — Infectious matters from without are 
introduced in a variety of ways. 

Cadaveric Poisoning. — Poison is probably in some cases con- 
veyed from the dissecting room and the autopsy table to partu- 
rient and puerperal women. Semmelweiss pointed out the 
difference in mortality among puerperal women in the two de- 
partments of the Vienna Lying-in Hospital. In the department 
attended by physicians and students the mortality was seldom 
below one in ten, while in that conducted solely by women, who 
did not visit the dissecting rooms, the mortality never exceeded 
one in thirty-four. The number of deaths in the former de- 
partment at once fell to that of the latter, when thorough disin- 
fection was employed. 



624: THE PUEEPEEAL DISEASES. 

There seems likewise to exist a difference between people in 
their liability to convey infection; for one practitioner will per- 
form frequent dissections and conduct numerous autopsies, and 
yet carry on an extensive midwifery practice with most satisfac- 
tory results; while another from a single visit to the dissecting 
or autopsy room will find that he has conveyed poison to his 
parturient and puerperal patients. It should be remembered, 
however, that the risk of conveying infection from a cadaver is 
greater when the subject died from zymotic disease. 

Erysipelas Infection. — Experience in private as well as hos- 
pital practice has conclusively shown that the infection from 
erysipelas may be communicated by the physician, or other per- 
sons, passing from a patient suffering with the disease, to the 
lying-in chamber. Still, such occurrences are comparatively 
rare, and are probably met only in the instances of women pos- 
sessing peculiar susceptibility to the infection, and attendants, 
medical or other, who ignore the ordinary usages of civilized 
society by not thoroughly cleansing their hands. That erysipe- 
las in a pregnant and finally parturient woman does not always 
add materially to the complications and dangers of the puerperal 
condition, was well illustrated in a case which occurred in Hahn- 
emann Hospital a few months since. A woman, during her ante- 
partum residence in the hospital, was attacked with erysipelas 
involving mainly the face, after a previous attack of diphtheria; 
and during the existence of the former disease, passed through 
labor. To the surprise of those acquainted with the case she 
made a good recovery. 

Scarlatinal Infection. — Certain zymotic diseases possessing 
symptoms peculiar to themselves, and quite uniform in their 
manifestations, may be so modified in a puerperal patient as to 
differ in no essentials from the phenomena usually presented by 
ordinary septicaemia. This does not appear to be true in every 
case, for puerperal women do, in some cases, manifest strictly 
scarlatinal symptoms, rather than those of septicaemia, and why 
the effects of the contagium should be so widely divergent in dif- 
ferent subjects, has not been clearly shown. We incline, how- 
ever, to the belief held by many, that, if the contagium be ab- 
sorbed through the skin or the ordinary channels, it may pro- 
duce its characteristic symptoms, and run its usual course; 



PUEKPERAL FEVER. 625 

while if brought into contact with lesions of continuity in the 
generative tract, it may act more in the way of septic poison, 
and with such intensity that its specific symptoms are not de- 
veloped. Spencer Wells says * that he has seen cases of surgi- 
cal pyaemia, which he had- reason to believe originated in the 
scarlatinal poison. 

Infection from Other Puerperal Women. ■ — Epidemics of 
puerperal fever outside of lying-in establishments have occurred, 
in by far the greatest number of cases, in the practice of some 
one physician or midwife, and they have generally been con- 
fined, therefore, to small districts, even in the large cities. Star- 
feldt, of Copenhagen, expresses the opinion that nurses most 
frequently form the media for transmission of the contagion. 
Distinction is made by some between sporadic and epidemic 
cases, the latter being regarded as far more infectious. In 
either instance, however, the signs, seats, lesions and results of 
the disease are the same, and who can discriminate between 
their manifestations ? A study of the history of puerperal fever, 
in hospital and private practice, and a rational view of the prob- 
abilities, we believe cannot fail to lead one to conclude that the 
infection is surely capable of being communicated from one 
patient to another through various media. 

How Long do the Septic Matters Retain their Infectious 
Properties ? — Another important question relates to the length 
of time that one may carry infectious matters about him. Some 
have claimed that it is impossible for any one to infect a woman 
in labor, in consequence of having performed an autopsy, hav- 
ing handled foul wounds, or having made a vaginal examination 
of a woman suffering from puerperal fever, two or three weeks 
previously. Schweninger believes that the putrid fluid loses its 
action after seven or eight months. Experimental research has 
not settled the question, but it seems probable, as suggested by 
Winckel, that such matters, by adhering to instruments, etc., 
probably retain their infectious properties as long as vaccine 
virus, i. e., for more than a year. 

How is the Contagium Conveyed?— "In all cases where the 
accoucheur has touched a woman in labor with his fingers or in- 

* Vide Playfair, loc. cit, p. 597. 



626 THE PUERPERAL DISEASES. 

struments," * says Winckel, "as well as with his clothing, and 
has subjected her to repeated examinations, we must, of neces- 
sity, rather impute the transmission of the infection to the 
hands or instruments; first, because the clothing is brought in 
contact with the denuded surfaces in the rarest instances only — 
and even then remains in contact with such a wound for a brief 
space of time — and finally, because the clothing is rarely so 
thoroughly impregnated with infectious matters as is often ob- 
served in case of the hands. If the objection be urged, that the 
disease may supervene, notwithstanding that the hands have 
been carefully cleansed and disinfected with chlorine water, or 
a solution of permanganate of potash, or dilute muriatic acid, 
the reply to this allegation is: that such washings, even if sev- 
eral times repeated, are far from being always thorough; that 
after numerous cleansings of this description, the hands may 
still retain an odor, from which it may be concluded that some 
morbid matter is still adherent to the fingers. It should not, on 
this account, however, be inferred that it is any the less impor- 
tant to wash the hands; this precaution should be uniformly 
taken, although we can pronounce the result of the same to be 
absolutely effective only when it has been many times repeated, 
and all odor has disappeared. For this reason it is of the great- 
est importance that accoucheurs of extensive practice, however 
careful in these ablutions, should never make autopsies, or, at 
least, should not attend a case of confinement for a number of 
days subsequent to such an examination, taking care even then 
to avail themselves scrupulously of the most effective means of 
disinfection." 

Infectious matters may be conveyed, then, by the hands or in- 
struments of the physician, by the hands of the nurse and by 
her implements, upon sponges, bed-pans and clothing, from 
patients suffering from puerperal fever, or any of the zymotic 
diseases, and from various other sources. 

Symptoms. — Puerperal fever is generally ushered in by 
chilly sensations, or a well-defined rigor, on the second or third 
day after delivery; rarely later than the fifth day. The symp- 
toms vary greatly, according to the organs or tissues more par- 
ticularly involved, but there is always elevation of temperature, 

* The Pathology and Treatment of Child-bed." Translation, 1876. 



PUERPERAL FEVER, 627 

enlargement of the spleen, arrested involution and sensitiveness 
of the uterus. 

Following is a brief resume of the clinical features of the 
local processes : 

Symptoms of Endometritis and Endocolpitis. — Uncomplicated 
catarrhal inflammation of the vagina and uterus is one of the 
mildest affections to which the puerperal woman is subject, and 
presents no reliable symptoms. In endometritis, involution is 
retarded, the after-pains are unusually severe, the lochia are 
fetid, and the uterus rather sensitive to pressure. In endocol- 
pitis the discharge is thin and purulent, and urination and def- 
ecation are attended with pain and burning. If ulcers form at 
the vulva, the labia are swollen and sensitive. The temperature 
in these cases seldom exceeds 102 ° or 103 ° . If the attack of 
endometritis prove severe, the discharge usually becomes brown- 
ish and thick, but is sometimes quite serous, irritative and fetid. 
The temperature may also rise to 104 ° or 105 ° . 

When we proceed further we find that the symptoms of endo- 
metritis and endocolpitis become merged into those of infection 
of the whole organism. 

Symptoms of Parametritis, Perimetritis, and Peritonitis. — The 
symptoms which accompany acute inflammation of the pelvic 
connective tissue are of great importance. It is not easy to dis- 
tinguish between parametritis and perimetritis, because the 
pain associated with the former is generally of such a character 
as to indicate the implication of the peritoneum. In fact, it 
must be very rare for one form to occur independently of the 
other; and we accordingly include under the head of parame- 
tritis those cases, which, from the moderate pain experienced, 
are more likely to belong there; while cases attended with in- 
tense suffering, with evidence of limited peritoneal inflamma- 
tion, we include under the head of perimetritis and pelvic peri- 
tonitis. 

Parametritis usually sets in on the second day, the febrile 
symptoms being preceded by a rigor in some cases, while i! 
others none is experienced. The temperature runs up quite rap 
idly, and attains its height either on the first day of the attack 
or the succeeding. It does not maintain a high level, but the 
remissions are marked, and in some cases become real intermis- 



628 THE PUERPERAL DISEASES. 

sions. Occasionally the temperature is at no time much above 
a normal point; but generally it is high, and may reach 105 ° 
and 106 ° . 

The pulse is usually accelerated to correspond with the ele- 
vated temperature; but when the latter has remained low, the 
former has, in some instances, been observed to become very fre- 
quent — symptoms always to be regarded with suspicion. 

The pain experienced is a prominent subjective symptom, and 
there is always sensitiveness to palpation, more especially on 
one side of the uterus or the other. 

Swellings are formed from infiltration of the cellular tissue, 
most frequently between the folds of the broad ligament, and 
constitute the pathognomonic sign of the affection, disclosed by 
conjoint touch. The resulting tumor is not always distinct. In 
one case the exudation lies so closely to the side of the uterus 
that the finger discovers only what appears to be an unusual 
thickness of the uterine structure on one side; and in another 
instance there is diffused exudation in the region of the internal 
os uteri, extending backward, and thus almost eluding the feel. 
The tumors are most frequently limited to one side, but in other 
cases they are found on both sides, but differing in size. They 
are often situated so high as to be felt with the greatest diffi- 
culty, and this explains why for so long a time they have been 
overlooked, or at least their frequency been underrated. Occa- 
sionally they extend so low as to encroach to a certain extent on 
the vagina. 

In somewhat rare instances the infiltration is especially ex- 
tensive in one iliac fossa or the other, in which case a vaginal 
examination will not reveal its existence, but on abdominal pal- 
pation the tumor is felt in the situation alluded to. 

After a time the contents of the tumors become more and 
more inspissated, and in the space of a few weeks or months are 
completely absorbed. Resorption of the exudation is accom- 
panied with the symptoms of hectic fever; but in favorable cases 
these soon disappear, the temperature falls to a normal level, the 
appetite returns, and health is soon restored. For a varying 
period the uterus is drawn to one side and fixed; but these con- 
ditions after a time disappear. 

Resorption does not always take place, owing, in some cases, 



PUERPERAL FEVER. 629 

to the existence of external irritations, and then the tumor di- 
minishes somewhat in size, becomes hard, and permanently 
remains. 

In comparatively rare instances suppuration ensues, the tu- 
mor becomes soft and sensitive, hectic fever sets in, and after a 
time the abscess perforates into the rectum, the vagina, the blad- 
der, the abdominal cavity, or the uterus. Occasionally the pus 
finds exit externally. 

Perimetritis. — The symptoms of pelvic peritonitis so closely 
resemble those of parametritis that the two diseases can scarcely 
be distinguished; and, indeed, they are also clinically more or 
less blended. Sharp pain, high fever, and tympanitic distension 
of the lower abdomen are generally regarded as symptomatic of 
inflammation of the pelvic peritoneum. When these are well 
marked, and the suffering is severe, should we find, after the ab- 
dominal sensitiveness has subsided, no objective signs of cellu- 
litis, we would be justified in regarding the case as one of pelvic 
peritonitis. Moderate fever, little pain and tympanitis, with 
evidence of exudation into the pelvic cellular tissue, would be 
good ground for a diagnosis of pure parametritis. 

Perimetritis, or pelvic peritonitis, generally begins with slight 
chilliness, or a marked rigor; but in some cases no such symp- 
toms are experienced. Then follow pain and tenderness at the 
sides of the uterus, accompanied with a rapid rise of tempera- 
ture. These symptoms may continue for a time and then yield to 
suitable treatment; or the inflammation may extend and general 
peritonitis follow. More frequently, however, the latter disease 
arises from parametritis as a consequence of pyaemic intoxica- 
tion, in which case the early symptoms much resemble those of 
pelvic peritonitis, but are more slowly developed. The pain 
increases in intensity, and is diffused over the abdomen; tym- 
panitis is manifested, and may become excessive, giving rise to 
dyspnoea; there is excessive sensitiveness to the least pressure; 
and the most patient women give expression to their sufferings 
in cries and groans. After extensive exudation, the pain de- 
creases in violence. Physical exploration is practiced with diffi- 
culty, but by means of gentle percussion we are sometimes able 
to discover evidences of exudation, and mark its slow changes 
of level upon turning the patient from one position to another. 



630 THE PUERPEKAL DISEASES. 

The febrile symptoms may be slightly remittent, or the flucL 
uations of temperature extensive. Sometimes the temperature 
follows a very irregular course, rising in some cases to 106 Q , and 
in others it remains remarkably low.* The pulse is more con- 
stant, but it occasionally becomes rapid only toward the fatal 
close of the disease. The pulse rises rapidly to 120, 130, or even 
160 beats per minute during the accession and extension of the 
inflammation. In fatal cases it becomes still more rapid, while 
the temperature finally descends. Increased rapidity of the 
pulse, occurring in connection with decline of the temperature, 
is always a bad symptom. The countenance has an anxious 
expression; the forehead is cold and moist; the extremities are 
also cold; and under symptoms of collapse the patient may sink 
in a few hours. 

Vomiting is usually present, though in some cases not even 
nausea is experienced. 

The mortality of puerperal peritonitis is very heavy. Death 
may occur in the early days of the attack, or even within thirty- 
six hours. 

When the disease terminates in recovery, the diffused exuda- 
tion sometimes becomes encapsuled, and the uterus agglutinated 
to contiguous structures. These conditions may even then ulti- 
mate in death, from suppuration of the exudation, or the induc- 
tion of a fresh attack of peritonitis. Even in favorable cases the 
adhesions are apt to give rise to colicky pains, displacements of 
the uterus, and sterility. 

Symptoms of Septicaemia Lymphatica, and Venosa. — The 
septic infection will vary considerably in its manifestations ac- 
cording to the channels through which it enters the system. In 

* Dr. Jacobi recently stated before the New York Obstetrical Society, (Am. 
Jour. Obs., vol. xiv, p. 123.), that the elevation of temperature was a very im- 
portant symptom, but that he had lost confidence in it as one of the main 
symptoms of peritonitis long ago. He had seen a number of fatal cases of 
peritonitis ranging through almost every age with very little elevation of tem- 
perature up to the last minute of life. High temperature ruas more likely to be 
absent in cases where there was septic poisoning. It was not uncommon for sepsis 
to lun a full course without an elevated temperature, or not above 101° or 102°. 

Dr. Emmet said at the same time, that the more malignant the form of per- 
itonitis, the more certainly would every characteristic sign be absent, and that 
this was due to blood poisoning. 



PUEEPEKAL FEVER. 631 

a large proportion of cases the lymphatics constitute such chan- 
nels, and the symptoms which result are of the most pronounced 
and dangerous kind. They appear soon after labor and are 
always introduced by a chill. The temperature mounts* to 104°, 
or higher, the pulse is small and frequent, the abdomen becomes 
tympanitic, but not generally sensitive, dyspnoea is experienced, 
and there may be bleeding at the nose. The peritoneal effusion 
is small, or entirely wanting, the tongue is moist and coated, or 
quite clean, and the bowels are sometimes loose. 

In most cases the patient is drowsy, restless, and somewhat 
delirious ; she utters few complaints, and can only be induced to 
give a rational response, by loud tones. She experiences a sense 
of comfort, and has little idea of her low condition. 

Pleurisy often forms a serious complication of the disease, 
and is rarely single. It sets in with the characteristic pains. 
Pericarditis is not uncommon, but since it is usually developed 
near the fatal close, its symptoms are generally overlooked. The 
joints .become the seat of suppurative inflammation, and the pain 
and tenderness are often very great. 

The percentage of recoveries from this form of septic infec- 
tion is surprisingly small. 

Venous septicaemia, or uterine phlebitis, arises "from putrid 
infection of the thrombus at the placental site. It sometimes 
takes place within twenty-four or forty-eight hours, but much 
more frequently its invasion is insidious, and appears to develop 
from a mild endometritis or parametritis. The rigor which 
marks its approach is usually violent, — in some cases lasting for 
hours. Then succeed heat and perspiration, as in intermittent 
fever, but the temperature does not often subsequently descend 
to a normal level. The pulse usually varies to correspond with 
the temperature. 

Disintegration of the thrombus gives rise to embolism in dis- 
tant organs, creating metastatic abscesses in the lungs, and other 
parts. The temperature maintains a higher, and more constant 
level, and the pulse becomes small and rapid. The patient be- 
comes soporous, slightly delirious, has a dry skin and tongue, 
with a moderately tympanitic abdomen, though this last condi- 
tion is often absent. 

The fatal result is usually postponed to the second or third 



632 THE PUERPERAL DISEASES. 

week, though it sometimes occurs within the first few days. The 
percentage of recoveries is small. 

Symptoms of Pure Septicemia. — Experience has shown thai 
in cases of intense septic infection death may take place in a 
very short time, and that the post-mortem examination reveals 
no other distinct changes than dark and non-coagulable blood, 
and ecchymoses into various tissues. The temperature rises 
rapidly, the pulse is accelerated, the patient is delirious, and 
afterward comatose, and death soon follows. In these cases the 
vital forces are probably overwhelmed by the intensity of the 
attack, before marked organic changes have had time to occur: 
but we have other examples of what might be termed pure 
septicaemia, following a more protracted course, and yet evincing 
no decided organic lesions. A common instance of this is found 
in the fever and other symptoms which result from the presence 
in utero of decomposing coagula or retained portions of the 
after-birth. The treatment, which consists in the removal oi 
the offending substances, is generally followed by complete and 
speedy disappearance of the unfavorable symptoms. 

Preventive Treatment. — The conscientious physician should 
not only himself adopt every reasonable precaution in his nec- 
essary attentions to parturient and puerperal women to preveni 
inoculation, or any form of infection, but he should insist upon 
the adoption, by others, of the strictest sanitary measures. 
That the neglect to do so results most disastrously, has been dem- 
onstrated beyond a peradventure, while disinfection has proved 
most salutary. The following statement of the results of the 
adoption of such measures in various maternities and hospitals, 
where infection is more especially looked for, must be convinc- 
ing even to the most skeptical. 

Braun von Fernwald* reports 61,949 confinements, occurring 
in sixteen years, in the Maternity Hospital of Vienna, out oi 
which number there were 825 deaths from puerperal fever, a 
percentage of 1.3. Dr. Johnston f reports from the Dublin 
Eotunda Hospital, during seven years, 7,860 births, with 85 
deaths from metria, or 1.08 per cent. Winckel J reports for the 

* " Lehrbuch der gesammten G-ynaek," p. 885. 

f " Clinical Reports," from 1870 to 1876. 

t li Berichte und Studien," Leipsic, 1874, p. 183. 



PUERPERAL FEVER. 633 

Lying-in Institution of Dresden 1.8 as the percentage of deaths 
from metria during 1873, while in 1872 it exceeded 5 per cent., 
the improvement being due to the exercise of greater precaution 
to avoid infection. In the Maternity Hospital of Copenhagen 
the mortality from metria, between 1865 and 1869, was 2.70 per 
cent.; but between 1870 and 1874, Stadfeldt,* reduced it to 1.15 
per cent. Dr. Goodellf reports, from the Preston Retreat, 756 
cases of labor, with only two deaths from septic disease. At Bres- 
lau, out of 901 births, Spiegelberg J lost but 5 cases from puer- 
peral fever. Buermann § says that in the Hopital Lariboisiere, 
under M. Siredey, in 1877, the death rate was 1 in 145, and in 
1878, 1 in 199; in the Hopital Cochin, under M. Polaillon, from 
1873 to 1877, it was 1 in 108.7; and in the same institution in 1877, 
there was but one death from puerperal causes, out of 807 
deliveries. 

The chief indications for effective prophylaxis are as 
follows : 

1. The prevention of the access of disease germs, both before 
and after labor, by the observance of antiseptic precautions. No 
vaginal examination should be made without first subjecting the 
hands to the action of soap and water, supplemented with the 
nail-brush, and subsequently with a mild, carbolic acid solution. 
The fingers should not be smeared with a lubricant which has 
been standing open in a sick room, or into which unclean fingers 
have been thrust. Cosmoline or vaseline should be used, by 
taking up some on the end of a clean knife-blade, and not by 
putting the fingers into the box. Instruments should not be 
used which have not been thoroughly washed and disinfected. 
In hospital practice, or wherever there is unusual danger of in- 
fection, it is well to place over the vulva, during labor, a cloth 
well saturated with a disinfectant solution. After delivery the 
utmost cleanliness ought to be practiced. It is highly important 
that the soiled clothes be removed as soon as possible, the 
vagina carefully syringed out, and the vulva washed with a car- 

* Les Maternities, leur organisation et administration." Copenhagen, 1876. 

f " On the Means Employed at the Preston Eetreat for the Prevention and 
Treatment of Puerperal Diseases," p. 13. 

X " Lehrbuch," p. 748. 

I " Recherches sur la Mortalite des Femmes en Couches dans les Hopitaux." 
Paris, 1879. 



634 THE PUERPERAL DISEASES. 

bolic acid solution. The napkins must be frequently changed. 
We believe also that, in uncomplicated cases, urination should 
be performed in the sitting posture, since the clots which form 
in the vagina are thus, by their own weight, extruded. The 
patient's general and special surroundings should be of a sani- 
tary nature. 

2. The destruction of septic germs which may have found en- 
trance. This can be done chiefly by the free use of antiseptics, 
more especially in the form of warm enemata — vaginal, and, in 
some cases, uterine. Still, unless there are grave suspicions of 
the presence of disease germs, such injections should not be 
often repeated. 

3. The closure of the open intra-uterine veins, lymphatics, 
and, perhaps, Fallopian tubes. To accomplish this, the uterus 
must be induced to firmly contract. The measures and reme- 
dies which favor such action have been mentioned in other 
chapters. 

Curative Treatment. — The initiatory rigor we are rarely 
called upon to deal with, inasmuch as it is often absent or but 
light, and when severe, frequently it is over before we have time 
to reach the bedside. If we can cut it short by suitable medica- 
tion, and other means, we ought to do so, inasmuch as the in- 
tensity of the pyrexia, and the severity of the succeeding or ac- 
companying inflammations, bear a certain relation to the dura- 
tion of the rigor. During the chill, bryonia, camphor a, aconite, 
veratrnm album, or arsenicum will probably be most suitable. 
Hot drinks, and moderate quantities of diffusible stimulants, 
may be given, while hot jars and bottles are applied to the body 
and extremities, and the amount of covering is increased. 

As soon as the reaction is established, and the temperature 
begins to rise, the choice of remedies will lie between aconite, 
veratrnm viride, belladonna and arsenicum. The indications 
for aconite are, briefly, a dry, hot skin, agonizing restlessness, 
generally intense thirst, rapid pulse, and suppressed lochia. 
Veratrnm viride has been used by some physicians, and promi- 
nently Dr. E. Ludlam, for the purpose of reducing the pulse 
•and temperature, it being given in every case when the tempera- 
ture goes above 102 ° , and the pulse is correspondingly acceler- 
ated. The special symptoms regarded as indications for the 



PUERPERAL FEVER. 635 

remedy, are high temperature, and full, rapid pulse. Arsenicum 
is called for by extreme restlessness, burning pains, dry 'heat 
with thirst, dry, parched lips, small, feeble pulse, and great pros- 
tration. Belladonna: Heat, with moist skin, dullness and qui- 
etness, excessive abdominal tenderness, suppression of the 
lochia, redness of the face, delirium, sleepiness, without ability 
to sleep, and generally little or no thirst. 

Subsequent symptoms vary greatly, according to the local 
lesion, and call for corresponding remedies, some of which we 
give a little further on. 

In those cases characterized by great prostration, without ex- 
cessively high temperature, wherein a profound alteration of the 
circulating fluid has taken place, and reaction seems doubtful, 
arsenicum and secale have given most satisfactory results. 

When peritonitis constitutes the most prominent localization 
of the septic intoxication, arsenicum, bryonia, and belladonna 
are frequently of service. 

Palliative Treatment. — For the pain of peritonitis in these 
desperate cases it is inhuman to deny palliative measures; but 
we should beware, in adopting them, not to do our patient harm, 
and materially lessen her chance of ultimate recovery. " For 
the relief of the pain of peritonitis," says Dr. E. Park,* "poul- 
tices have been prescribed as a routine. This is a practice, how- 
ever, which the writer feels is highly dangerous, and cannot be 
too severely deprecated, as, if the pain be due to an incipient 
peritonitis, it is amazing with what rapidity it spreads under the 
fostering warmth of a hot poultice. Care must therefore be 
taken to make as accurate a diagnosis as possible of the cause of 
the pain; but, at all events, to make sure it is not due to an in- 
cipient peritonitis. In cases where it can reasonably be con- 
strued to be due to any other cause, as e. g., painful and partial 
uterine contractions, retention of lochia and clots, cellulitis, me- 
tritis, etc., poultices will at once contribute to the relief of the 
pain as a symptom, and, in some instances, to the removal of the 
cause by resolution or suppuration, etc. And, again, in cases of 
completely developed peritonitis, light and often-changed poul- 
tices are of infinite value for soothing of pain and promotion of 
resolution under systemic treatment." 

•" Glasgow Medical Journal," Oct., 1880. 



636 THE PUEBPEEAL DISEASES. 

If the suffering in peritonitis is for a time extreme, we may 
regard the administration of morphia, preferably by hypoder- 
mic injection, as justifiable; but if not unbearable, the prejudi- 
cial effect of the drug should be avoided. In no case should its 
use be long continued, and when once the disease is fully devel- 
oped, poultices will afford sufficient relief. 

Regimen. — The decided tendency of the disease to produce 
prostration indicates the importance of sustaining the vital pow- 
ers by an abundance of easily assimilated nourishment. Various 
forms of animal soups, strong beef -tea, and the yolk of eggs 
beaten up with brandy, should be given at intervals of not more 
than two or three hours, in quantities as great as the patient can 
well be induced to take. The digestive powers may be aided by 
the administration of pepsin. Nausea and vomiting are apt to 
be provoked by the ingestion of food, though they frequently 
arise without such an exciting cause, and require medication. 
Peculiar symptoms may point to particular and unusual reme- 
dies ; but those which are most likely to control the complica- 
tion are arsenicum, bryonia, and ipecac. 

A certain amount of stimulation will be found beneficial, but 
it must be varied to correspond with the character of the symp- 
toms present. When the temperature runs high, the pulse is 
rapid and thready, there is much low delirium, tympanites, sweat- 
ing and other indications of profound exhaustion, whisky or 
brandy may for a time be given in teaspoonf ul doses every hour, 
with good effect. Larger quantities are sometimes used with 
decided benefit. 

The Use of Antiseptic Injections.— When we have reason 
to believe that retained shreds of membrane, or adherent por- 
tions of the placenta, have given origin to the septic state, or 
when there are evidences of ulcerative metritis, accompanied 
with high temperature and the other familiar symptoms, intra- 
uterine injections of a solution of carbolic acid have produced 
decided improvement. The favorable effect of such injections 
on the hyperpyrexia is often most marked. When intra-uterine 
injections are not indicated, or are thought to be inadvisable, the 
vagina should be syringed with a similar solution. For such 
injections a syringe like the Higginson or the Fountain, with 



PUERPERAL FEVER. 637 

long tube should be used, as otherwise air is liable to be injected 
into the uterine cavity, a thing always to be carefully avoided. 

We look for favorable results from the hypodermic injection 
of phenic acid. The antiseptic effects of this remedy are un- 
questionable, and its employment, according to Declat's method, 
will doubtless prove most salutary. 

Retained Fragments of Secundines. — Where it is suspected 
that there is still in utero an adherent placenta, foetid membranes, 
a decomposing clot, or vitiated lochia, it becomes the physician's 
first duty to explore the interior of the organ, and remove all 
offending substances. To do this it will generally be advisable 
to introduce four fingers, previously well smeared with some 
bland lubricant, into the uterus. This should be done under 
anaesthesia. Before removing the hand it is advisable to wash 
out the cavity with a stream of warm carbolated water. If more 
than two or three weeks have elapsed since delivery, but a single 
finger can be introduced; but by means of that, with the half 
hand in the vagina, the object can be effected. If the finger 
cannot easily be introduced, the dull curette or small blunt hook 
may be used. 

Relief of Tympanitic Distension. — Tympanites generally 
accompanies peritonitis, but it is often observed in connection 
with other puerperal conditions, and may require special atten- 
tion. Arnica, lycopodium, china, carbo veg. (in potency, or 
charcoal in teaspoonf ul doses, ) or colocynih will usually afford 
relief; but should these remedies fail, a rectal tube maybe care- 
fully introduced, or the colon punctured in the right iliac fossa 
with a large hypodermic needle. Before entering the needle, 
a broad bandage should be passed around the body, so that 
pressure may be brought to the aid of the paralyzed bowels, in 
effecting complete evacuation of their gaseous contents. 

General Therapeutics. — Aconite. — High temperature, hard, 
rapid pulse, dry skin, intense thirst, sensitive abdomen, shoot- 
ing pains. 

Arsenicum. — Burning, throbbing, lancinating pains; great 
restlessness, anguish and fear of death; thirst for frequent sips 
of water, though they disagree; wants to be warmly covered. 

Belladonna. — The pains are often of a clutching or clawing 



638 THE PUERPERAL DISEASES. 

nature, though not always, and come and go quickly. Sensation 
of weight and bearing in the pelvis; throbbing headache, with 
red face and eyes; raving delirium; lochia suppressed, or very 
foetid; the parts are exquisitely sensitive to the touch. 

Bryonia. — Her sufferings are aggravated by the least motion. 
She has splitting headache, dry, parched lips, and considerable 
thirst. 

Calcarea carb. — An occasional dose of this remedy will be 
found beneficial in women of leucophlegmatic temperament. 

China. — When the attack succeeds profuse hemorrhage, this 
remedy, unless previously administered, should always be given. 

Creosotum. — Is well suited to endometritis, with the usual 
foetid discharges. 

Kali carb. — The most marked symptoms of this remedy are 
the stitching, cutting, shooting, and darting pains. There are 
great thirst and rapid pulse. 

Lachesis. — This is also well suited to endometritis. The hy- 
pogastrium is very sensitive, and the lochia are foetid. She 
always feels worse on awaking from sleep. 

Nux vomica. — The symptoms only occasionally point to this 
remedy. It should be given as an introductory remedy, if the 
patient has been taking drugs in quantities. Other symptoms 
are heaviness and burning through the pelvic region; severe 
pain in the lumbo-sacral region; scalding and burning on urinat- 
ing, with frequent desire. She is despondent, and sleepless, or 
has frightful dreams. 

Rhus tox. — Great depression of the vital forces growing out 
of the septic infection; delirium; dry tongue; extreme restless- 
ness; offensive lochia; worse after midnight. 

Secale cor. — This remedy appears to be peculiarly well indi- 
cated in many cases of puerperal fever, and has rendered good 
service. The lochia are foetid; the abdomen is distended, but 
not very sensitive; and the urine is scanty. There are also of- 
fensive diarrhoea, delirium, and sometimes vomiting. 

Sulphur. — This excellent remedy should be administered 
in occasional doses, as it sometimes appears to give point and 
efficiency to remedies well indicated by the pathology and symp- 
tomatology of the case. 






INDEX 



Abdomen: 

appearance of in pregnancy, 134. 

pain in during pregnancy, 252. 

size of in pregnancy, 126, 157. 

striae upon in pregnancy. 134. 
Abdominal pregnancy, 165. 
Abdominal muscles, action of in la- 
bor, 281. 
Abdominal tumors: 

diagnosis of, from pregnancy, 149. 
Abortion, 182. 

artificial, 239, 262, 426, 514. 

causes, 183. 

definition of, 182. 

diagnosis of, 192. 

incomplete, 188. 

moles of, 233. 

symptoms of, 186. 

treatment of, 194. 

neglected cases of, 207. 

of one foetus in twin pregnancy, 
191, 200. 
Abscess in mastitis, 604. 

in phlegmasia dolens, 592. 

sub-mammary, 607. 
Accidental hemorrhage, 472. 

treatment of, 475. 
Accoucheur, armamentarium of, 299. 
Acetabulum, 27. 
Acephalus, 445. 
Acrania, 445. 
Adherent placenta, 503. 
After-pains, 582. 



Air, effect of entry into uterine ves- 
sels, 600. 
Air-passages, catheterization of in 

asphyxia neonatorum, 510. 
Albuminuria in pregnancy, 244. 

relation of to eclampsia, 246. 

treatment of, 247. 
Allantois, 94. 
Amnion, 92. 

anomalies of, 222. 

dropsy of, 222. 
Anencephalus, 445. 
Amniotic fluid, 93. 

excess of, 222. 

deficiency of, 224. 
Amputations, intra-uterine, 230. 
Anaemia: 

in pregnancy, 242. 

treatment of, 242. 
Anaesthesia and anaesthetics, 310, 
327. 

in eclampsia, 616. 

in normal labor, 310, 327. 

in operative midwifery, 328. 

rules for administering. 330. 
Anasarca, maternal, 242. 
Anchylosis of sacro-coccygeal joint. 

34. 
Animation, suspended, 508. 
Anteflexion, uterine, in pregnancy. 

258. 
Anteversion, uterine, in pregnancy. 
258. 

639 



640 



INDEX. 



Antiseptic treatment of puerperal 

patients, 636. 
Aorta, compression of in postpar- 
tum hemorrhage, 499. 
Arbor vitse, 66. 
Area germinativa, 90. 
Area pellucida, 91. 
Area vasculosa, 91. 
Areola, 81. 
changes of, in pregnancy, 133. 
secondary of Montgomery, 133. 
Arm, presentation of, 376. 

dorsal displacement of, 447. 
Armamentarium of obstetric physi- 
cian, 299. 
Articulations: 
pelvic, 32. 
mobility of, in labor, 37. 
relaxation of, in pregnancy, 37. 
rupture of, 34. 
Artificial respiration: 
Sylvester's method, 510. 
Marshall Hall's method, 511. 
Schroeder's method, 511. 
Schultze's method, 511. 
Howard's method, 511. 
Artificial respiration in asphyxia ne- 
onatorum, 510. 
Ascites, foetal, obstructing labor, 

445. 
Asphyxia neonatorum, 508. 

treatment of, 509. 
Astringents, use of, in post-partum 

hemorrhage, 499. 
Atony, uterine, in the third stage of 

labor, 394. 
Atresia, uterine, 401. 
Atrophy of uterine mucous mem- 
brane, causing abortion, 184. 
Attitude of foetus, 111. 
Auscultation, as a means of diagno- 
sis of pregnancy, 146. 
Auscultation, as a means of diagno- 
sis of position and presenta- 
tion, 119. 
Auscultation, as a means of diagno- 
sis of twin pregnancy, 121. 
Auscultation, as a means of diagno- 
sis of the sex of foetus, 121. 



Axis: 

of pelvic brim, 43. 

of pelvic outlet, 43. 

of pelvic canal, 43. 

of parturient canal, 44. 
Ballottement, 145. 
Basilaire, 29. 

Bath of new-born infant, 588. 
Battledore placenta, 100. 
Bed, arrangement of for labor, 307. 
Binder, uses of, 323. 
Bladder: 

calculus in, obstructing labor, 405. 

dilatation of foetal, 445. 
Blastodermic membrane, 90. 
Blastodermic vesicle, 90. 
Blighted ovum, 233. 
Blood, changes of, in pregnancy, 135 
242. 

alteration in after delivery, 575. 

transfusion of, 545. 
Blunt hook, large, in breech presenta- 
tion, 542. 

small, in abortion, 206. 
Bowels, action of, after delivery, 577, 

586. 
Breech presentation: 

causes, 367. 

configuration of foetal head in, 374. 

mechanism of, 367. 

dangers in, 366. 

rotation in, 368. 

forceps in, 539. 
Breasts: 

anatomy of, 80. 

anomalies of, 80. 

changes in during pregnancy, 132. 

diseases of: 
abscesses, 604. 
mastitis, 604. 
galactorrhoea, 602. 
nipples, sore, 602. 
treatment of nipples, 603. 
treatment of mastitis, 606. 
Bregma, 108. 
Brim of pelvis, 39. 

diameters of, 40. 

use of forceps at, 532. 

extraction with head at, 375. 



INDEX. 



64:1 



Brow presentation, 365. 
Csesarean section: 558. 

indications for, 433. 

preparations for, 560. 

description of operation, 560. 

prognosis of, as to the woman, 559. 

prognosis of, as to the child, 559. 

statistics of, 559. 

treatment after, 566. 

post-mortem operation, 566. ' 
results of, 567. 

substitutes for, 568. 

causes of death after, 558. 
Cadaveric poisoning: 

puerperal, 623. 
Calcareous degeneration: 

of foetus, 166, 231. 

of placenta, 100. 
Calculus: 

vesical, obstructing labor, 405. 
Canal, pelvic, axis of , 43. 

of Nuck, 63. 
Caput succedaneum, 292, 353. 
Carcinoma of the cervix obstructing 

labor, 402. 
Cardiac diseases, complicating preg- 
nancy, 266. 
Caries of teeth in pregnancy, 253. 
Carunculse myrtiformes, 52. 
Catheterization: 

of bladder, 543. 

of uterus, for premature deliv- 
ery, 513. 

of air passages in asphyxia neona- 

' torum, 510. 
Cauda equina, 30. 
Cellulitis, pelvic, 619. 
Cephalic presentations, 333. 
Cephalic version, 516. 

mode of performing in transverse 
presentation, 382. 
Cephalalgia in pregnancy, 241. 
Cephalotribe, 553. 
Cephalotripsy, 553. 
Cervix uteri, 62. 

artificial dilatation of for prema- 
ture labor, 513. 

changes of in pregnancy, 127, 144. 

atresia of, 401. 



carcinoma of, obstructing labor, 

402. 
canal of, 65. 
cysts of, 67. 

mucous membrane of, 66. 
glands of, 67. 
rigidity of, in labor, 396. 
incision of, 399. 
lacerations of, 483. 
hemorrhage from laceration of, 488, 

Child: 

asphyxia of, 508. 

weight of, 104. 

care of, 588. 
Childbirth, mortality of, 572. 
Chill, post-partum, 573. 
Chloroform in labor, 310, 327. 

in operative procedures, 328. 

in eclampsia, 616, 

effect of on pains, 329. 
Chorea in pregnancy, 249. 

Chorion: 

formation of, 90. 

permanent, 94. 

villi of, 94. 

degeneration of, 212. 
Circulation of feetus, 104. 
Cleavage of yolk, 89. 
Clitoris, anatomy of, 48. 
Coccyx, anatomy of, 31. 

anchylosis of, 34. 

mobility of, 34. 
Coiling of funis, 226. 
Colostrum, 589. 
Commissures of vulva, 47. 
Complex presentations, 385. 
Conception, 86. 
Confinement, prediction of day of, 

156. 
Conjugate diameter of pelvis, 

true and false, in pelvic measure- 
ments, 422. 
Conjoined twins, 439. 
Conjoint manipulation, version by, 

519. 
Constipation in pregnancy, 255. 
Constriction, uterine, tetanoid, 400. 
Continued fever in pregnancy, 369. 



642 



INDEX. 



Contracted pelvis: 

diagnosis of, 421. 

labor in, 426. 

mode of extraction in, 429. 
Contractions, uterine, 278, 281. 

vaginal, 280. 
Convulsions, puerperal, 610. 

causes of, 610. 

prognosis in, 613. 

treatment for, 613. 
Cord, umbilical, 100. 

mode of tying, 317. 

unligatured, 317. 

dressing of stump, 588. 

coiling of, 226. 

cysts of, 227. 

hernia of, 227. 

structure of, 100. 

management of, when about the 
neck, 317. 

marginal insertion of, 100, 228. 

prolapse of, 465. 

reposition of, 469. 

torsion of, 226. 
Cordiform uterus, 72. 
Corpus luteum: 

true, 85. 

false, 84. 
Corpus reticule, 93. 
Cough in pregnancy, 256. 
Cramps in pregnancy, 254. 
Cranioclast, 552. 
Craniotomy: 

cases requiring, 549. 

comparative merits of cephalotrip- 
sy and cranioclasm, 554. 

description of cephalotripsy, 553. 

frequency of, 550. 

use of craniotomy forceps, 551. 

perforators, 550. 

method of perforating, in head-last 
cases, 444. 

contrasted with Cesarean section. 
555. 

crotchet in, 550. 
Craniotomy forceps, 551. 
Cranium, foetal, 107. 
Credo's method of placental delivery, 
320. 



Crotchets, use of , 550. 
Cystocele, obstructing labor, 404. 
Cysts: 

of cord, 227. 

conduct of labor when complicated 
by ovarian, 408. 
Death: 

apparent, of new-born child, 508. 

foetal, diagnosis of, 150. 

real or apparent, of mother in preg- 
nancy or labor, delivery of child 
in case of, 566. 

sudden, of mother, in labor and 
childbed, 599. 
Decapitation of foetus, 385, 555. 

methods of, 555. 
Decidua, 95. 

reflexa, 95. 

vera, 95. 

serotina, 95. 

separation of, 96. 

pathology of, 208. 
Decollator, 555. 

use of, 555. 
Deformities, pelvic, 413. 

due to exostosis, 419. 

due to fractures, 421. 

contracted pelvis, 413. 

flattened pelvis, 414. 

funnel-shaped pelvis, 417. 

JNTaegele oblique pelvis, 417. 

osteomalacic pelvis, 415. 

pseudo-osteomalacic pelvis, 415. 

rachitic pelvis, 414. 
Degeneration: 

calcareous, of foetus, 166, 231. 

fatty, of foetus, 232. 

hydatidiform, of chorion, 213. 
Delivery: 

state of patient after, 573. 

contraction of uterus after, 575. 

management of patient after, 572. 

nervous shock after, 575. 

prediction of date of, 156. 

state of pulse after, 574. 

weight of uterus after, 125. 

post-mortem by Caesarean sec, 566. 

post-mortem through natural pas- 
sages, 568. 



INDEX. 



643 



Diameters of pelvis, 40. 

of foetal head, 109. 
Diarrhoea in pregnancy, 255. 
Diet, of the lying-in, 585. 
Digital examination in labor, 301. 
Dilatation, manual, 391,399. 
Discus proligerus, 78. 
Diseases, etc., complicating pregnan- 
cy: 

abdominal pains, 252. 

albuminuria, 244. 

anemia, 242. 

breasts, painful, 252. 

cardiac diseases, 266. 

cephalalgia, 241. 

chorea, 249. 

constipation, 255. 

cough, 256. 

cramps, 254. 

diarrhoea, 255. 

displacement of uterus in, 258. 

dyspnoea, 256. 

endometritis, 208. 

eruptive fevers, 268. 

face-ache, 241. 

haemorrhoids, 256. 

hysteria, 250. 

hydatidiform mole, 213. 

insomnia, 242. 

leucorrhoea, 252. 

malarial fever, 269. 

paralysis, 251. 

pneumonia, 269. 

pruritus, 241. 

ptyalism, 240. 

rubeola, 267. 

side, pain in, 252. 

syncope, 271. 

syphilis, 271. 

toothache, 253. 

typhoid fever, 268. 

varicose veins, 257. 

vesical irritation, 256. 

vomiting, 137, 236. 
Displacements of uterus, 258. 
Double uterus, 71. 
Douglas, cul-de-sac of , 63. 
Douche, vaginal, 

for premature delivery, 514. 



in puerperal state, 579. 
Dropsies of foetus and membranes, 

complicating pregnancy, 229. 
Ducts of M uller, 71. 
Ductus arteriosus, 105. 
Ductus venosus, 105. 
Dystocia from foetus, 434. 
Dyspnoea in pregnancy, 256. 
Eclampsia: 

clinical history of, 610. 

etiology of, 610. 

pathology of, 610. 

prognosis in, 613. 

treatment of, 613. 
Ecraseur, use of for foetal decapita- 
tion, 555. 
Ectoderm, 90. 
Electricity: 

in vomiting of pregnancy, 238. 

in extra-uterine pregnancy, 178. 
Elytrotomy, 170. 
Embolism, 599, 621. 
Embryo cell, 89. 
Embryo, definition of, 101. 
Embryo, development of, 101. 
Embryotomy, 555. 
Emesis: 

in incarceration of retroflexed uter- 
us, 260. 

in pregnancy, 236. 
Endochorion, 94. 
Endocolpitis, puerperal, 618. 
Endometritis, puerperal, 618. 
Endometritis in pregnancy, 208. 
Entoderm, 90. 
Epileptic convulsions, 613. 
Episiotomy, 314. 

Ergot, mode of administration, 494. 
Eruptive fevers in pregnancy, 268. 
Erysipelas: 

relation of to puerperal fever, 624. 
Ether, use of, 329, 330. 
Eustachian valve, 105. 
Evisceration, 556. 
Evolution, spontaneous, 379. 
Examination of parturient women, 

301. 
Exanthemata in pregnancy, 2i>S. 
Exochorion, 94. 



64A 



INDEX. 



Exostosis, pelvic deformity from, 

419. 
Expelling powers of labor, 278. 
Expression of placenta, 320. 
Extraction of fcetus: 

in Cesarean section, 564. 

in pelvic presentations, 369, 375. 

in real or apparent death of mother 
in pregnancy or labor, 566. 

of head, 375. 
Extra-uterine pregnancy, 164. 

abdominal variety of, 165. 

tubal variety of, 168. 

interstitial, 167. 

ovarian, 165. 

tubo-abdominal, 168. 

tubo-ovarian, 165. 

treatment of, 176. 
Eace presentation, 355. 

etiology of, 356. 

diagnosis of, 116. 

mechanism of, 355. 

mento-posterior positions in, 364. 

prognosis in, 360. 

configuration of head in, 360. 

treatment of, 362. 
Fallopian tubes, 73. 
False labor-pains, 284, 304. 
Fatty degeneration of foetus, 232. 
Fatty degeneration of placenta, 219. 
Fecundation, 86. 
Fever: 

malarial, in pregnancy, 269. 

milk, in pregnancy, 580. 

typhoid, in pregnancy, 268. 

typhus, in pregnancy, 268. 

relapsing, in pregnancy, 268. 

puerperal, 617. 
Fibroid tumors: 

differential diagnosis of, 149. 

complicating labor, 406. 
Fillet: 

use of, in breech presentations. 540. 

use of, in version, 523. 
Floor, pelvic, 59. 
Fceces, impacted, obstructing labor, 

405. 
Fcetus: 

anatomy and physiology of, 101. 



appearance of, at various stages of 
development, 102. 

circulation of, 104. 

changes in position and presenta- 
tion during pregnancy, 113. 

position and attitude of, in utero, 
111. 

cranium of, 107. 

weight of, at term, 104. 

diagnosis of position of, 115. 

by palpation, 117. 

by auscultation, 119. 

by vaginal examination, 115. 

viability of, 104. 

dropsies of, 229. 

nutrition of, 93. 

death of, 150. 

deformities of, 445. 

pathology of, 228. 

abdominal enlargement of, 445. 

congenital hydrocephalus of, 442. 

fatty degeneration of, 232. 

extraction of: 
by breech, 540. 
in breech and foot presentations, 

369, 375. 
in craniotomy, 550. 
with forceps, 534. 

heart- sounds of, 119, 121, 146. 

hydrothorax of, obstructing labor, 
444. 

large, 446. 

maceration of, 232. 

monstrosities of, 445. 

movements of, 141. 

mummification of, 231. 

retention of, dead, 180, 231. 

syphilis of, 229. 

tumors of, obstructing labor, 445. 

viability of, 104, 155. 

violence, effects of on, 229. 
Follicles, Graafian, 77. 
Fontanelles, 108. 
Footling presentation, 372. 
Foramen ovale, 105. 

obturator,27. 

sacro-sciatic, 36. 
Forceps: 

action of, 530. 






INDEX. 



645 



application of, 534. 

varieties of, 532. 

head at or above the brim, 532. 

head in pelvic cavity, 533. 

or outlet. 533. 

in occipito-posterior 
positions, 537. 

to after-coming head, 540. 

to breech, 539. 

cephalic mode of, 533. 

pelvic mode of, 532. 

in face presentation, 539. 
craniotomy: 

description of the operation, 534. 
history of, 525. 
long, 526. 

in connection with rigid os, 399. 
removal of the blades, 536. 
short, 326. 

salient features of, 528. 
use of anaesthetics in connection 

with, 533. 
in uterine inertia, 393. 
varieties of, 527. 
direction of traction" with, 535. 
placenta and ovum, in abortion, 
204. 
Fornix, vaginal, 55. 
Fossa navicularis, 52. 
Fourchette, 52. 
Fractures: 
causing pelvic deformity, 421. 
intra-uterine, 229. 
Fundus uteri, 62. 
Funis: 
pathology of, 225. 
care of stump of, 588. 
coiling of, 226. 
cysts of, 227. 
hernias of, 227. 
knots in, 225. 

marginal insertion of, 100, 228. 
prolapse of, 465. 

causes, 467. 

diagnosis, 468. 

prognosis, 467. 

treatment, 469. 
stenosis of vessels of, 228. 
torsion of, 226. 



ligature of, 317, 588. 
Funnel-shaped pelvis, 417. 
Galactorrhea, 602. 
Gastrotomy: 

after uterine rupture, 482. 

in extra-uterine pregnancy, 178. 
Gastric derangements of pregnancy, 

236. 
Gastro-elytrotomy, 570. 
Gastro-hysterotomy, 558. 
Gelatine of Wharton, 101. 
Generation: 

anatomy of female external organs 
of, 47. 

anatomy of female internal organs 
of, 61. 
Genital canal: 

ruptures of, 316, 478, 483. 

uterine atresia of, 401. 
Germinal (or germinative) vesicle, 

78. 
Germinal (or germinative) spot, 78. 
Gestation, duration of, 151. 
Glands, mammary: 

anatomy, 80. 

changes in produced by pregnancy, 
132. 
Glands, sebaceous, of nymphse, 52. 
Glands, uterine, 67. 
Glands, vaginal, 57. 
Glands, vulvo- vaginal, 52. 
Glans clitoridis, 48. 
Graafian follicles, anatomy of, 77. 
Graafian follicles, physiology of, 83. 
Gravidity, signs of, 140. 
Hematocele, obstructing labor, 403. 
Haemorrhoids, in pregnancy, 256. 
Hand, dilatation of os with, 391, 399. 
Hand, manner of introducing in po- 
dalic version, 521. 

when to introduce for delivery of 
placenta, 503. 
Head, foetal: 

anatomy of, 107. 

diameters of, 109. 

various positions of, 334. 

presentations of, 111. 

application of forceps to: 
in head-first cases, 534. 



m 



INDEX. 



in head-last cases, 540. 
configuration of in various pres- 
entations and positions, 354, 
360, 365, 373, 425. 
at brim, forceps to, 532. 
in cavity, forceps to, 533. 
at outlet, forceps to, 533. 
change of position of, by manipu- 
lation, 537. 
change of presentation of, by ma- 
nipulation, 362. 
flexion of, 344. 
rotation of, 344. 
extension of, 346. 
restitution of, 346. 
scalp-tumor on, 292, 353. 
influence of sex on size of head, 
110. 
Headache in pregnancy, 241. 
Head-last deliveries: 
treatment of arms in, 373. 
breathing space for foetus in, 373. 
forceps in, 373. , 
Heart: 
diseases of in pregnancy, 266. 
changes in, wrought by pregnancy, 
136. 
Heart-sounds, foetal, 119, 121, 146. 
Hemophilia, 487. 
Hemorrhage: 
accidental, 472. 
concealed internal, 474. 
external, 474. 
treatment of, 475. 
from cervical laceration, 488. 
from vestibular laceration, 489. 
in abortion, 187. 
in placenta prsevia, 451. 
post-partum, 485. 
varieties of, 485. 
causes of, 486. 
constitutional predisposition to, 

487. 
premonitory symptoms of, 489. 
prognosis of, 493. 
preventive treatment of, 493. 
concealed, 490. 
c mcealed, spurious, 491. 
curative treatment of, 495. 



compression of uterus in, 496, 

497. 
various modes of exciting uterine 
contractions, 496, 497. 
post-partum, secondary, 492. 
treatment of, 500. 
unavoidable, 449. 
Hemorrhagic diathesis, 487. 
Hernia: 
of cord, 227. 

of pregnant uterus, 264. 
Hook: 
blunt, large, 542. 
blunt, small, 206. 
decapitating, 555. 
Hour-glass contraction, 502. 
Hydatidiform degeneration of cho- 
rion, 213. 
treatment of, 217. 
Hydramnios, 222. 
as cause of tardy labor, 224. 
clinical history of, 222. 
treatment of, 224. 
Hydrocephalus of foetus, 442. 
as cause of tedious labor, 442. 
conduct of labor m, 444. 
Hydrorrhoea gravidarum, 211. 
Hydrothorax, foetal, 444. 
Hygiene of pregnancy, 235. 
Hymen: 
anatomy of, etc., 51. 
as an obstacle to delivery, 406. 
Hypertrophy of uterine mucous 
membrane as a cause of abortion, 
185. 
Hypodermic injections, mode of giv- 
ing, 543. 
Hysteria during pregnancy, 250. 
Hysterotomy, vaginal, 401. 

gastro, 558. 
Ilia, anatomy of, 28. 
Ilio-sacral synchondrosis, 33. 
Impregnation, 86. 
Incarceration: 

of retrofiexed uterus, 260. 
Inertia of the uterus, 389. 

treatment of, 391. 
Infant: 
apparent death of, 508. 



INDEX. 



647 



new-born, first attentions to, 558. 

changes in circulation of, 105. 

umbilicus of, 588. 
Infectious diseases complicating 

pregnancy, 268. 
Injuries during pregnancy, 254. 

Injections: 

hot water intra-uterine, for hem- 
orrhage, 497. 

styptic, intra-uterine, for hemor- 
rhage, 499. 

in puerperal septicaemia, 636. 

vaginal, to produce premature la- 
bor, 514. • 

to prevent auto-infection, 579. 

hypodermic, method of giving, 543. 
Innominate bones, 26. 

Insanity: 

of lactation, 595. 

of pregnancy, 137, 593. 

puerperal, 594. 

transient mania, of labor, 593. 
Insertio valamentosa, 100. 
Insomnia in pregnancy, 242. 
Intra-pelvic muscles, 79. 
Inversion of uterus, 504. 
Involution, uterine, 575. 
Iron, injection of in post-partum 

hemorrhage, 499. 
Irregular uterine contractions, dur- 
ing labor, 400. 

after labor, 501. 
Ischia,planes of the, 45. 
Ischia, anatomy of, 28. 

Joints: 

movement of pelvic, in labor, 37. 

pelvic, 32. 
Kidneys, pathological changes of, in 

eclampsia, 611. 
Kiestein, 138. 
Knots of the funis, 225. 
Knee presentation, 366. 
Labia majora, 47. 

commissures of, 47. 

cedema of, 243. 

thrombosis of, 403. 

minora, 50. 



Labor: 
abdominal muscles, action of in, 

281. ' 
anaesthesia in, 310, 327. 
care of the woman after, 323. 
causes of, 273. 

contractions, vaginal, in, 280. 
contraction of uterine ligaments 

in, 280. 
contractions, uterine, effects of, in, 

278, 281. 
duration of, 296. 
diagnosis of, 303. 
expelling powers, action of, 278. 
has it begun, 303. . 
hour of, 297. 

management of normal, 298. 
mechanism of, 332. 
induction of, 512. 
in occipito-anterior position of 

vertex, 343, 348. 
in occipito-posterior position of 

vertex, 349. 
in mento-anterior positions of face 

presentation, 361. 
in mento-posterior positions of face 

presentation, 357, 361. 
in brow presentation, 365. 
in breech presentation, 367. 
membranes, rupture of, in, 308. 
missed, 180. 

rational management of, 298. 
obstructed by uterine polypi, 406. 
obstructed by maternal soft parts, 

396. 
pains of, character and source, 281. 
pains, influence of on the organism, 

280. 
phenomena of, 283. 
pains, false, 284, 304. 
position of patient during, 307. 
precipitate, 389. 

preliminary preparations for, 298. 
prolonged, 389. 

protection of perineum in, 312. 
protracted, 389. 
premature, 183. 
modes of inducing, 512. 
stages of, 283. 



648 



INDEX. 



swelling, diffuse obstructing, 406. 

premonitory symptoms of, 284. 

pulse during, 286. 
* therapeutics of, 324. 

tedious, 389. 

tide, relation of, to hour of, 297. 

uterine ligaments, contraction of, 
in, 280. 

uterine contractions in, 278, 281. 

weak, 389. 
Laceration: 

of cervix uteri, 483. 

of genital canal, 483. 

of perineum, 316. 

of uterus, 478. 

of vestibule, 484. 

of vessels, 488. 
Lactation: 

defective secretion of milk in, 601. 

excessive secretion of milk in, 602. 

fever of, 580. 

insanity of, 595. 

means of arresting secretion of 
milk in, 5S2. 
Laparo-elytrotomy, 570. 
Laparotomy, 178, 482. 
Leucorrhcea in pregnancy, 252. 
Lever (vectis), 541. 
Leverage action of forceps, 531. 
Ligaments, pelvic, 35. 

uterine, 63. 

contractions of in labor, 280. 
Linea alba, in pregnancy, 142. 
Liquor amnii, 93, 101. 

anomalies of, 225. 
Line, ilio-pectineal, 27, 39. 
Lithopsedion, 166, 174, 182. 
Lochia: 

varied characters of, 578. 

variation in amount and duration 
of, 579. 
Locking: 

of children in multiple pregnancy, 
' 438. 

Lumbo-sacral articulation, 30. 
Lying-in period, duration of, 686. 
Lymphatics of uterus, inflammation 

of, in puerperal fever, 630. 
Maceration of foetus, 232. 



Malacosteon, as a cause of pelvic de- 
formity, 420. 
Malarial fever in pregnancy, 269. 
Malformations of child, 445. 
Mammae: 

abscess of, 604. 

anatomy of, 80. 

anomalies of, 80. 

changes of in pregnancy, 132. 

secretion of milk in, 580. 

pain in, during pregnancy, 252. 
Management of labor, 298. 
Mastitis puerperalis, 604. 
Mania, puerperal, 593. 
Manual dilatation of os, 391, 399. 
Marginal insertion of cord, 100. 
Meatus urinarius, 50. 
Measles in pregnancy, 267. 
Mechanism: 

of labor, 332. 

abnormal, in vertex presentations, 
350. 

abnormal, in face presentations, 
359. 

occipitoanterior positions of 
vertex, 342, 348. 
occipito-post positions of 
vertex, 349. 

of face presentations, 355. 

of breech presentations, 366. 

of brow presentations, 365. 

of transverse presentations, 375. 
Melancholia in pregnancy, 137. 
Membranes, artificial rupture of, 308. 

artificial rupture of, to prevent 
post-partum hemorrhage, 495. 

puncture of, to induce labor, 512. 

puncture of, in accidental hemor- 
rhage, 476. 

puncture of, in placenta prsevia, 
456. 

spontaneous rupture of, 291. 
Membrane, blastodermic, 90. 
Menstruation: 

cessation of, 140. 

during pregnancy, 141. 

corpus luteum of, 84. 
Mesoderm, 91. 
Metritis, puerperal, 619. 



INDEX. 



649 



Milk: 

defective secretion of, 601 . 

excessive secretion of, 602. 

appearance of after delivery, 580. 

means of arresting secretion of, 
582. 
Milk-fever, 580. 
Milk-leg, 589. 
Migration of ovum, 85. 
Miscarriage, 182. 
Missed labor, 180. 
Moles: 

of abortion, 233. 

carneous, 233. 

sanguinosa, 233. 

hydatidiform, 213. 

true and false, 233. 

treatment of, 233. 
Monstrosities, 231, 445. 
Mons veneris, 47. 
Montgomery, secondary areola of, 

133. 
Morning sickness, 137, 236. 
Morsus diaboli, 73. 
Mortality of child-bed, 572. 
Movements, foetal, 141. 
Mucous membrane of uterus, 66. 
Muller's ducts, 71. 
Multiple pregnancies, 434. 

arrangement of membranes in, 435. 

diagnosis of, 121. 

causes of, 434. 

conduct of labor, 436. 

in abortion, 191. 

locking of children in, 438. 
Mummification, foetal, 231. 
Naegele oblique pelvis, 417. 
Nausea of pregnancy, 137, 236. 
Navel, characters of, in pregnancy, 

134. 
Navel of new-born child , 588. 
Nerves of uterus, 69. 
Nervous shock after delivery, 573. 
Neuralgia in pregnancy, 241. 
Nipples: 

changes in during pregnancy, 132. 

depressed, 601. 

sore, 002. 
Nutrition of foetus, 93. 



Nymphae, 50. 

sebaceous glands of, 50. 
Obliquely contracted pelvis, 417. 
Obstructed labor, from— 

abnormalities of foetus, 434. 

arm, dorsal displacement of, 447. 

agglutination of os uteri, 401 = 

obliteration of cervical canal, 
401. 

ascites, foetal, 445. 

overloaded foetal bladder, 445. 

cystocele, 404. 

cord, coiling of, 226. 

foeces, impacted, 405. 

fibrous growths, 406. 

hydrocephalus, foetal, 442. 

hydro thorax, foetal, 444. 

hymen, unruptured, 406. 

monstrosities, 445. 

from pelvic deformity, 413. 

perineum, rigidity of, 410. 

pregnancy, multiple, 436. 

rigid os uteri, 396. 

tumors: 
ovarian, 408. 
uterine, 406. 

twins, locked, 438. 
Obturator ligament, 37. 
Obturator foramen, 27. 
Occipito-posterior positions: 

difficult cases of, 349. 

abnormal mechanism of, 3-50. 

forceps in, 537. 

conversion of, into anterior posi- 
tions, 352. 
Odontalgia, in pregnancy, 253. 
(Edema: 

associated with eclampsia, 246. 

in pregnancy, 243. 

of vulva, in pregnancy, 243. 
Oophorohysterectomy, 568. 
Operations: 

Caesarean section, 558. 

craniotomy, 549. 

embryotomy, 555. 
Forceps, 525. 

for producing abortion, 239, 262, 

426, 514. 
for inducing labor, 512. 



650 



INDEX. 



Porro's, 568. 

Thomas', or laparo-elytrotomy, 570. 

catheterism, 543. 
Organs, generative, 47. 

female, anatomy of, 47. 

changes in produced by pregnancy, 
125. 
Osteomalacia as a cause of pelvic de- 
formity, 420. 
Osteophytes, 136. 
Ossa innominata, 26. 
Os uteri, 62. 

agglutination of, 401. 

dilatation of in labor, 289. 

causes of, 289. 

imprisoned anterior lip of, in labor, 
311,402. 

slow dilatation of in labor, 397, 
391. 

manual dilatation of, 391, 399. 

instrumental dilatation of, 399. 

rigidity of, 396. 
Os tincae, 62. 
Ovarian: 

pregnancy, 165. 

tumors obstructing labor, 408. 
Ovaries: 

anatomy of, 74. 

physiology of, 83. 

escape of ovum from, 83. 

tumors of in pregnancy and partu- 
rition, 408. 

vessels and nerves of, 79. 
Ovaro-hysterectomy, 568. 
Oviducts, 73. 
Ovulation, 83. 
Ovum or ovule: 

anatomy of, 78. 

post-fecundative changes in, 89. 

escape from ovary, 83. 

discus proligerus of, 78. 

germinative spot of , 79. 

germinative vesicle of, 78. 

migration of, 85. 

pathology of, 208. 

premature expulsion of, 182. 

segmentation of yolk of, 89. 

vitelline membrane of , 78. 

vitellus of, 78. 



yolk of, 78. 
zona pellucida of, 78. 
blighted, 233. 
Ovum and placenta forceps, use of, 
204. 

Pains: 
after-, 582. 

in abdomen during pregnancy, 252. 
irregular or inefficient in labor, 

391. 
labor, 281. 
weak, 391. 

effect of chloroform on 3 329. 
Palpation, abdominal, as a means of 
diagnosis of position and pres- 
entation, 117. 
Paralysis in pregnancy, 251. 
Parametritis, 619. 
Parturient canal, axis of, 44. 
Pathology: 
of decidua and ovum, 208. 
of pregnancy, 164. 
of labor, 388. 
Patient, how to approach, 299. 
Patient's bed and dress, 307. 
Pelvis: 
measurements of, 40. 
external, 41,422. 
internal, 41,422. 
mode of taking in living subject, 

422. 
instruments for, 422. 
method of taking with the hand. 
422. 
deformity of, 413. 
anatomy of, 25. 
divisions of, 39. 

difference between male and fe- 
male, 45. 
axes of, 43, 44. 
movements and relaxation of joints 

of during labor, 37. 
ligaments of, 35. 
causes of deformity of, 420. 
induction of premature labor in de- 
formity of, 426. 
induction of abortion in deformity 
of, 426. 



INDEX. 



651 



turning and forceps in deformity 

of, 429. 
craniotomy in deformity of, 432. 
funnel-shaped, 417. 
Caesarean section in deformity of, 

433. 
uniformly contracted, 413. 
flattened, 414. 
flattened, generally contracted, 

415. 
uniformly enlarged, 413. 
infantile type of, 418. 
mechanism and modes of delivery 
in deformed pelvis, 429, 432, 
433. 
prognosis of, 425. 
planes of, 42. 
rachitic, 415. 
malacosteon, 415. 
effect of deformity of on pains, 

424. 
obliquely contracted, 417. 
deformity of as a cause of prolapse 

of funis, 467. 
Kobert's, 418. 

effect of deformity of on presenta- 
tion, 424. 
effect of deformity of on labor, 424. 
deformity of brim of as a cause of 

uterine traumatism, 425. 
spondylolisthetic, 419. 
deformed by — 
absence of symphysis, 420. 
exostosis, 419. 
fractures, 421. 
osteomalacia, 420. 
rachitis, 420. 
sacral flattening, 417. 
sacral curve, 417. 
floor of, 59. 
inclination of, 41. 
soft parts of, 47. 
Pelvic: 
deformity, 413. 
cellulitis, 619. 
organs, functional disturbance of 

in pregnancy, 135. 
peritonitis, 620. 
presentations, 366. 



positions of, 335. 
mechanism of, 368. 
dangers in, 366. 
use of forceps in, 539. 
mode of extracting head in, 375. 
mode of applying the forceps, 532. 
Penniform rugae, 66. 
Perforation: 
instruments for, 550. 
extraction of child after, 551. 
Perineorraphy, immediate, 411. 
Perineum: 
incision of, in labor, 315. 
laceration of, in labor, 316. 
support of, in labor, 313. 
rigidity of as an obstacle to labor, 

410. 
rotten, 410. 
Peritonitis: 
diffuse, 621. 
pelvic, 620. 
puerperal, 620. 
Phenomena of labor, 283. 
Phlebitis, uterine and para-uterine, 

621. 
Phlegmasia alba dolens, 589. 
Phthisis in pregnancy, 270. 
Physician, attendance of, on puer- 
peral women, 585. 
Placenta, 96. 
apoplexy and inflammation of, 221. 
anatomy of, 96. 
physiology of, 96. 
pathology of , 99. 
battledore, 100, 228. 
delivery of, 320. 
artificial separation and removal 

of, 502. 
changes preparatory to separation, 

100. 
expression of, 319. 
detachment of in normal labor, 

294. 
degeneration of, 219. 
development of, 96. 
functions of ,*99. 
inflammation of, 221. 
praevia, 449. 
varieties of, 450. 



652 



INDEX. 



diagnosis of, 452. 
prognosis of, 454. 
causes of, 448. 

causes of hemorrhage in, 449. 
clinical history of, 451. 
treatment of, 454. 
retained, 502. 
syphilis of, 220. 
size of, 218. 
succenturise, 99, 218. 
Placentitis, 221. 
Planes of pelvis: 
horizontal, 42. 
ischial (inclined), 45. 
Plexus: 
pampiniform, 69. 
uterine, 69. 
Plural pregnancy, 434 (see "multiple 
preg.) 
arrangement of placentae and mem- 
branes in, 435. 
causes of, 434. 
diagnosis of, 121. 
position of foetuses in, 436. 
sexes of foetuses in, 434, 435. 
management of, 436. 
locking of twins in, 438. 
in abortion, 191. 
Pneumonia in pregnancy, 269. 
Podalic version, 517. 
Polypi complicating labor, 406. 
Porro's operation, 568. 
Portio vaginalis of cervix uteri, 62. 
Positions, 332. 
classification of, 333. 
relative frequency of, 340. 
forceps, use of, in occipito-poste- 

rior, 537. 
points of coincidence between, 340. 
conversion of occipito-post. into 

occipito-ant., 352. 
favorable, and unfavorable, 362. 
difference between, and presenta- 
tions, 114. 
diagnosis of, 115. 
Post-partum hemorrhage, 485. 
Post-partum blood changes, 574. 
Powers, expelling, of labor, 278. 
Precipitate labor, 389. 



Pregnancy: 
abdominal pains in, 252. 
abdomen, increased size of, in, 126, 

157. 
albuminuria in, 244. 
abdominal walls, changes in, in, 

134. 

accidents in, 254. 

anemia, pernicious, in, 242. 

auscultation in, 119, 146. 

accidents during, 254. 

ballottement in, 145. 

bladder and rectum, functional 

disturbances of, in, 135. 
blood-changes of, 135, 242. 
cardiac changes in, 136. 
cardiac diseases in, 266. 
cough in, 256. 
constipation in, 255. 
cephalalgia in, 241. 
cervix uteri, changes of, in, 127, 

144. 
cramps in, 254. 
changes wrought by, 125. 
chorea in, 249. 
digestive system, derangement of, 

in, 236. 
dead foetus, diagnosis of, in, 150. 
diseases of, 234. 
diagnosis of, 139. 
diagnosis, differential, of, 149. 
diarrhoea in, 255. 
duration of, 151. 
dyspnoea in, 256. 
end of, prediction of, 156. 
endometritis during, 208. 
eruptive fevers during, 268. 
examination, physical, in, 141. 

methods of, in, 141. 

by palpation, 143. 

by auscultation, 146. 

by inspection, 141. 

by percussion, 145. 
extra-uterine, 164. 

abdominal, 165. 

interstitial, 167. 

ovarian, 165. 

tubal, 168. 

tubo-abdominal, 168. 



INDEX. 



653 



tubo-interstitial, 168. 

tubo-ovarian, 165. 
face-ache in, 241. 
fevers, continued, in, 268. 
foetal heart-sounds in, 119, 121, 146. 
fundus, height of at various stages 

of, 158. 
gastric disturbances of, 137, 236. 
hemorrhoids in, 256. 
headache in, 241. 
history of symptoms as data for 

diagnosis of, 140. 
hygiene of, 235. 
hydraemia, in, 243. 
hysteria during, 250. 
injuries during, 254. 
insalivation in, 240. 
insomnia in, 242. 
inspection of the signs of, 141. 
interruption, premature, of, 182. 
in rudimentary cornu of a one- 
horned uterus, 170. 
leucorrhoea in, 252. 
maculae in, 138. 
malarial fever in, 269. 
mammary changes in, 132. 
mammary pains in, 252. 
management of, 235. 
mania in, 137. 
melancholia in, 137. 
menstrual suppression in, 140. 
menstruation during, 141. 
morning sickness of, 137, 236. 
movements of foetus in, 141. 
multiple, 434. 

conduct of labor in, 436. 

diagnosis, 121. 

frequency of, 434. 

locking of foetuses in, 438. 

varieties of, 434. 
nausea and vomiting of, 137, 236. 
navel, changes of, in, 134. 
nervous system, effects of, on, 137. 
nipple, changes of, in, 132. 
oedema in, 243. 
operations, surgical, in, 265. 
osteophytes, formation of, in, 136. 
os uteri, changes of, in, 127, 144. 
palpation for diagnosis of, 143. 



paralysis in, 251. 

pathology of , 164. 

percussion in, 145. 

permanent changes of, 138. 

phthisis in, 270. 

pneumonia in, 269. 

protracted, 155. 

permanent changes of, 138. 

pruritis in, 241. 

ptyalism of, 240. 

quickening in, 141, 157. 

rubeola in, 267. 

scarlatina in, 268. 

side, pain in during, 252. 

signs of, 140. 

spurious, 159. 

surgical operations during, 265. 

syncope in, 251. 

syphilis in, 271. 

toothache in, 253. 

touch, vaginal, in, 115. 

twin, diagnosis of, 121. 

typhoid and typhus fevers compli- 
cating, 268. 

urine, characters of , in, 138. 

uterine displacements in, 258. 

uterine bruit (souffle), in, 147. 

uterine textural changes in, 125. 

uterine subsidence near close of 
127. 

uterus: 
intermittent contractions of, as 

a sign of, 143. 
prolapse of, in, 127. 
change in size, etc., during,126. 

vagina, changes in, in, 132, 144. 

varices in, 257. 

variola in, 268. 

vesical irritation in, 256. 

vulva, changes in, in, 132. 

without menstruation, 140. 
Premature labor, 183, 512. 
Premature labor in pelvic deformi- 
ty, 426. 

in paralysis of preg.,251. 
Preparations for labor, 307. 
Presentations, 111, 332. 

etiology of, 111. 






654 



INDEX. 



difference between presentation 

and position, 114. 
diagnosis of, 115. 
pelvic, 366. 
causes of, 367. 
extraction of head in, 375. 
configuration of head in, 373. 
liberation of arms in, 373. 
positions of, 335. 
brow, 365. 
face, 355. 
positions of, 333. 
causes of, 356. 
forceps, use of, in, 539. 
form of head in, 360. 
diagnosis of, 116. 
mechanism of, 355. 
conduct of labor in, 362. 
footling, 372. 
normal, 341. 
abnormal, 341. 
shoulder, 376. 
podalic version in, 383. 
cephalic version and forceps in, 
383. 
transverse, 375. 
in twin pregnancy, 121. 
complex, 385. 
vertex, 342. 
positions of, 333. 
diagnosis of, 116. 
cause of preponderance of, 342. 
Primitive trace, 91. 
Prolapse: 
of funis, 465. 
of gravid uterus, 263. 
Propulsive stage of labor, 292. 
Pruritus in pregnancy, 241. 
Pseudocyesis, 159. 
Ptyalism in pregnancy, 240. 
Pubes, anatomy of, 28. 
Pubic arch, 29, 32. 
Pudendum, 47. 
Pudendi, rima, 50. 
Puerperal diseases, 589. 
Puerperal eclampsia, [vide eclampsia.) 

610. 
Puerperal fever, 617. 



definition of, 617. 

classification of lesions of, 618. 

nature of , 617. 

pathological anatomy of, 618. 

septicaemia in, 617. 

virus of, 623. 

contagium,how conveyed, 625. 

clinical history of, 626. 

causes of, 623. 

pleurisy in, 631. 

diphtheritic patches in, 619. 

symptoms of endocolpitis and of 

endometritis in, 627. 
symptoms of general peritonitis in, 

629. 
symptoms of parametritis in, 627. 
symptoms of perimetritis in, 629. 
symptoms of septicaemia in, 632. 
pericarditis in, 631. 
erysipelas, how related to, 624. 
diet in, 636. 

treatment of, 

preventive, 632. 

curative, 634. 

palliative, 635. 

intra-uterine injections in, 636. 

vaginal injections in, 636. 

poultices in, 635. 

tympanites in, 637. 
Puerperal mania, 593. 
Puerperal state, 
management of, 322 , 572. 
pulse in, 574. 
bowels in, 586. 
temperature in, 575. 
visits of physician in, 585. 
diet in, 585. 

hygienic considerations in, 584. 
lochia in, 578. 
after-pains in, 582. 
getting up, time for, in, 586. 
uterine involution in, 575. 
uterine mucous membrane, 

changes in, 577. 
milk fever in, 580. 
urination in, 585. 
secretion of milk in, 580. 

means for arresting, 582. 
skin, condition of, in, 574. 









INDEX. 



655 



phenomena immediately succeed- 
ing delivery, 573. 

vaginal douches in, 579. 

vaginal changes in, 578. 
Pulmonary thrombosis, 599. 
Pulse, state of, after delivery, 574. 

during labor, 286. 
Pyaemia, in puerperal fever, 617. 
Quickening, 141. 

time of its occurrence, 103, 157. 
Rachitis, deformed pelvis from, 420. 
Eectocele, 405. 

Eectum, impaction of foeces in, 405. 
Repercussion, (vide ballottement,) 

145. 
Eepositor, uterine, 262. 
Respiration: 

artificial, methods of, for foetus, 
510. 
Restitution, movement of, 346. 
Retention: 

placental, 502. 

foetal, 180, 231. 

urinary, 585. 
Retroflexion of gravid uterus, 259. 
Retroversion of gravid uterus, 259. 
Rigidity: 

of os uteri, 396. 

of perineum, 410. 
Rima pundendi, 50. 
Rotation of foetus: 

in vertex presentation, 293, 345, 
349, 352. 

in face, 358. 

in breech, 368. 
Rubeola, in pregnancy, 267. 
Rupture: 

of perineum, 316. 

of uterus, 478. 

of vagina, 483. 

of vestibule, 484. 
Sac, amniotic: 

puncture of in extra-uterine preg- 
nancy, 177. 

injections into, in extra-uterine 
pregnancy, 177. 
Sacrum, anatomy of , 29. 

movement of in labor, 37. 

mechanical relations of, 33. 



Sacro-iliac articulation, 33. 
Sacro-coccygeal articulation, 34. 

anchylosis of, 34. 
Salivation in pregnancy, 240. 
Sapraemia, 617. 
Scarlatina: 

in pregnancy, 268. 

in puerperality,624. 
Scybalae obstructing labor, 405. 
Section, Caesarean, 558. 

post-partum, 566. 
Secretion: 

lacteal, deficient, 601. 
excessive, 602. 

salivary, excessive, 240. 
Segmentation of yolk, 89. 
Semen, 87. 

Septicaemia: 
in puerperal fever, 617. 
channels of septic absorption, 623. 
auto-genetic and hetero-genetic 

forms of, 623. 
sources of infection, 623. 
treatment of, 632. 
Sex: 
foetal, diagnosis of during preg' 

nancy, 121. 
influence of, on size of foetal head, 
110. 
Shoulder presentations: 
mechanism of, 376. 
podalic version in, 383. 
cephalic version and forceps in, 
383. 
Sinuses, closure of, in puerperal 

state, 577. 
Sleeplessness, in pregnancy, 242. 
Small-pox, in pregnancy, 268. 
Souffle, uterine, 147. 
Spermatozoa, 87. 
course of to point of fecundation. 
88. 
Sphincter vaginae, 55. 
Spondylolisthetic pelvis, 419. 
Spontaneous evolution and expul- 
sion, 379. 
Spot, germinative, 78. 
Spurious pregnancy, 159. 
Stages of labor, 283. 



656 



INDEX. 



State, puerperal, 

management of, 572. 

pulse in, 574. 

temperature in, 575. 

visits of physician in, 585. 

diet in, 585. 

lochia in, 578. 

after-pains in, 582. 

closure of sinuses in, 577. 

condition of skin in, 574. 

uterine involution in, 575. 

milk fever in, 580. 

urination in, 586. 

secretion of milk in, 580. 

phenomena immediately succeed- 
ing delivery, 573. 

vaginal douches in, 579. 
Stenosis of umbilical vessels, 228. 
Stethoscope, manner of using, 146. 

Strait: 

superior. 39. 

axis of, 43. 

inferior, 39. 

axis of, 43. 
Striae of pregnancy, 134. 
Styptics in post-partum hemorrhage, 

499. 
Superf ecundation, 435. 
Superfcetation, 435. 
Surgery, obstetric, 512. 
Surgical operations during preg- 
nancy, 265. 
Suspended animation, 508. 
Sutures of foetal cranium, 108. 
Swelling, diffuse, obstructing labor, 

406. 
Symphysis pubis, 32. 

absence of, 420. 

anatomy of, 32. 
Symphysotomy, 570. 
Syncope: 

in pregnancy, 251. 

in puerperality, 600. 
Synchondrosis, ilio-sacral, 33. 
Syphilis in pregnancy, 271. 
Syringe, hypodermic, manner of 

using, 543. 
Tampon, 198. 



mode Of applying, 198. 

in abortion, 198. 

in placenta prsevia, 457. 

to induce labor, 514. 
Temperature after delivery, 575. 
Tetanoid constriction of the uterus, 

400. 
Thrombosis: 

peripheral venous, 589. 

clinical history of, 589. 

treatment of, 592. 

puerperal, 
causing collapse and death, 599. 

of vagina, 403. 

of vulva, 403. 
Toothache in pregnancy, 253. 
Torsion of cord, 226. 
Touch, vaginal, in pregnancy and 

labor, 115, 301. 
Trace, primitive, 91. 
Tractions, on forceps, 

direction of, 535. 

time for making, 535. 
on foetal body, 432. 
on head in delayed expulsion of 
shoulders, 316. 
Transfusion: 

of blood, 545. 

mode of performing, 545. 

of milk, 548. 
Transverse presentations, 375. 

causes of, 377. 

positions of, 336. 

treatment of, 381. 
Trunk: 

presentation of, 375. 

expulsion of, 379. 
Tubal pregnancy, 168. 
Tubes, Fallopian, anatomy of, 73. 

action of their fimbriated extremi- 
ties, 74. 
Tumors: 

differential diagnosis of, from 
pregnancy, 149. 

foetal, causing dystocia, 445. 

osseous, deforming pelvis, 419. 

ovarian, in parturition, 408. 

parametritic, in puerperal fever, 
628. 



INDEX. 



657 



fibroid, in labor, 406. 

phantom, 159. 
Tunica albuginea, 75. 
Turning, [vide version), 515. 
Twins: 

diagnosis of, 121. 

conduct of labor with, 436. 

locking of during birth, 438. 

conjoined, 439. 

in abortion, 191. 
Tympanites: 

in puerperal fever, 637. 
Typhoid and typhus fevers in preg- 
nancy, 268. 
Umbilical cord, 100. 

knots of, 225. 

torsion of, 226. 

coiling of , 226. 

ligature of, 317, 588. 

prolapse of, 465. 

hernia of, 227. 

anomalies of insertion of ,100, 228. 

dressing of, 588. 

early and late ligature of, 318. 

cysts of, 227. 

marginal insertion of, 100, 228. 

non-ligation of, 317. 

stenosis of vessels of, 228. 
Umbilical vesicle, 92. 
Umbilical vessels, stenosis of, 228. 
Umbilicus: 

changes of, in pregnancy, 134. 

of infant, 588. 
Unavoidable hemorrhage, 449. 
Uraemia and eclampsia, 610. 
Urethra, 50. 
Urinary calculus, obstructing labor, 

405. 
Urine, peculiarities of during preg- 
nancy, 138. 

albumen in, during pregnancy, 244. 

necessity of drawing before using 
the forceps, 534. 

passing, in puerperality, 585. 

Uterine: 
elevator, 262. 
souffle, in pregnancy, 147. 
inertia, 389. 



fluctuation as a sign of pregnancy, 
145. 

tumors, obstructing labor, 406. et 
seq. 
Uterus: 

anatomy of, 61. 

anomalies of, 71. 

axis of gravid, 258. 

anteversion and anteflexion of, 258. 

atrophy of mucous membrane, as 
a cause of abortion, 184. 

bicornis, 72. 

body of, 62. 

cancer of neck of, complicating la- 
bor, 402. 

cannon-ball contraction of, 488. 

catheterization of, 513. 

cavity of, 64. 

cervix of, 62. 

contractions of, in pregnancy, 143. 

contractions of, in labor, 278, 281. 

changes in cervix uteri, 
during pregnancy, 127. 

cordiformis, 72. 

corpus of, 62. 

changes in form and size, 126, 157. 

changes in situation, 127. 

changes in tissues of, 126. 

development of, 70. 

dimensions of, 61. 

displacements of, during pregnan- 
cy, 258. 

double. 71. 

fundus of, 62. 

glands of, 67. 

hour-glass contraction of, 502. 

height of fundus of, at different 
stages, 126, 157. 

hernias of gravid, 264. 

hypertrophy of mucous membrane 
of, 185. 

inclination of gravid, 127. 

injections, into the, 
of hot water, 497. 
of styptics, 499. 
antiseptic, 636. 

inertia of, 389. 

inversion of, 504. 
treatment of, 506. 



658 



INDEX. 



involution of, after labor, 575. 

laceration of, 478. 

cervix of, 483. 

ligaments of, 63. 

lymphatics of, 70. 

manual compression of, after and 
during labor, 322. 

mucous membrane of, 66. 

muscular fibres of, 65. 

nerves of, 69. 

perforation of, from pressure. 479. 

prolapse of gravid, 263. 

regional division of, 62. 

relations of, in advanced pregnan- 
cy, 135. 

retroversion of gravid, 259. 

retroflexion of gravid, 259. 

rupture of, 478. 
clinical history of, 480. 
causes of, 479. 
conduct of cases of, 480. 

septus bilocularis, 72. 

size of, at various stages of preg- 
nancy, 26, 157. 

situation of, change in during preg- 
nancy, 127. 

tumors of, complicating labor, 406. 

tetanoid constriction of, 400. 

utricular glands of, 67. 

unicornis, 71. 

vessels of, 68. 

weight of, after delivery, 125. 

walls, thickness of at close of ges- 
tation, 126. 

Vagina: 
anatomy of, 54. 

changes of, in pregnancy, 132, 144. 
contraction of, in labor, 281. 
columns of, 56. 
double, 71. 
glands of, 57. 
examination of, 115. 301. 
laceration of, 483. 
sphincter of, 55. 
orifice of, 50, 55. 
tampon of, 198, 457, 514. 
thrombus of, 403. 
walls of, 55. 
mucous membrane of, 56. 



Vaginal douche to induce labor, 514. 

in puerperal state, 579. 
Valve: Eustachian, 105. 

of foramen ovale, 106. 
Varicose veins in pregnancy, 257. 
Variola in pregnancy, 268. 
Vectis: action of , 541. 

use of, 541. 

Veins: 

varicose, in pregnancy, 257. 

entrance of air into, as a cause of 
sudden death after delivery, 600. 
Vernix caseosa, 104, 588. 

Version: 
cephalic, 516. 
bimanual, external, 516. 
by conjoint manipulation, 519. 
conditions favorable for, 516. 
conditions calling for, 515. 
anaesthesia in, 521. 
choice of hand to be used, 521. 
in deformed pelves, 430. 
in placenta prsevia, 461. 
in transverse presentation, 382. 
in prolapse of funis, 472. 
in rupture of uterus, 481. 
use of fillet in, 523. 
neglected, 384. 
podalic, 517. 

podalic, external method, 518. 
podalic, combined external and in- 
ternal, 519. 
podalic internal, 520. 
position of patient in, 518. 
spontaneous, 379. 

Vertex, 342. 

presentation, mechanism of, 342. 

configuration of head in, presen- 
tation of, 354. 

positions of, 333. 
Vesicle: 

blastodermic, 90. 

germinative, 78. ♦ 

umbilical, 92. 
Vesical irritation in pregnancy, 256. 

vesical distension of the foetus,445. 
Vesico-uterine ligaments, 63. 
Vesical calculus, 405. 






INDEX. 



659 



Vessels: 

collapse and death from entrance 
of air into, 600. 

umbilical, stenosis of, 228. 
Vestibule, 50. 

bulbs of, 53. 

glands of, 50. 

laceration of, 484. 
Viability, foetal, 104, 155. 
Villi of chorion, 94. 
Visits of physician to puerperal pa- 
tient, 585. 
Vitelline membrane, 78. 
Vitellus of ovum, 78. 
Vitriform body, 93. 
Vomiting, of pregnancy, 137, 236. 

in retroflexion of the uterus, 260. 
Vulva, 47. 



changes of, in pregnancy, 132. 

oedema of, 243. 

thrombus of, 403. 
Vulvo-vaginal glands, 52. 
Weak labor, 389. 
Weight: 

of woman, increase of, in preg- 
nancy, 138. 

of foetus at term, 104. 

of non-pregnant uterus, 125. 

of uterus after delivery, 125. 
Wharton's gelatine, 101. 
Wounds of foetus, 229. 
Yolk of ovum, 78. 
Zona pellucida, 78. 
Zymotic diseases: 

their relation to puerperal fever, 
626. 



NOVEMBEB, 1882. 



DESCRIPTIVE CATALOGUE 



OF 



GROSS & DELBBIDGE'S 



HOMCEOPATHIC 



Medical Woeks. 



For Sale at all Homoeopathic Pharmacies, or 
will be sent prepaid on receipt of price. 



CHICAGO: 

GEOSS & DELBEIDGE. 

1882. 



GEOSS & DELBEIDGE'S Publications. 



A Physiological Materia Medica, containing all that is 
known of the Physiological Action of our Kemedies, their 
Characteristic Indications, and their Pharmacology. By W. 
H. Burt, M. D. Chicago : Gross & Delbridge. 1881. 992 
pages. Cloth, $7 ; Sheep, $8. Third edition. For sale by 
Homoeopathic Pharmacies, or sent free by the Publishers, on 
receipt of price. 

We believe that no book on Materia Medica in our literature so 
completely meets the requirements of the Physician and Student 
as this ; and, as proof of the correctness of this opinion, we have 
to announce the sale of the entire first edition in ninety days. 
Such a reception has never been awarded before to any book in 
Homoeopathic literature. The demand for the work indicates that 
its appearance was opportune, and that its plan and execution 
are approved by the Profession. We have received a large num- 
ber of favorable notices both from Physicians and the Press, from 
which we make the following selections : 

Dr. Burt has brought together in a compact and well-arranged form an im- 
mense amount of information. The profession will fully appreciate the labor 
and skill with which the author has presented the physiological and patho- 
logical action of each drug on the organism. — New York Medical Times. 

W e are sure that Dr. Burt's new work will have deservedly a rapid sale. 
Gross & Delbridge are a new publishing house in the medical line ; but cer- 
tainly they must be old hands in the business, for paper and printing leave 
nothing to be desired. May they never falter in such laudable work, and the 
eyes of the readers will bless them forever. — Dr. Lilienthal in North Ameri- 
can Journal of Homoeopathy. 

An enthusiastic yearning for the whys and wherefores of our wondrous 
Therapeutic art has brought Dr. Burt to the front again among the best book- 
makers of our time. — St. Louis Clinical Review. 

Dr. Burt has enriched our literature with many valuable contributions, and 
the work before us gives proof of the value of his well directed labors. — 
Detroit Medical Observer. 

We can recommend the book as full of interesting and profitable reading. 
— Hahnemannian Monthly. 

Dr. Burt has the power of sifting the tares from the wheat. — Chicago Med- 
ical Times. 
We cordially recommend Dr. Burt's book.— New England Medical Gazette. 

Have just received Burt's Materia Medica. It is a work long needed, and 
the printing and binding are a credit to your house.— JR. W. Nelson, M. D. 

It is a keystone of medical study, and the printing and binding are the very 
best. — 67. H. Morrison, M. D. 

The work is a credit to Chicago. — Medical Investigator. 

GROSS & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



GEOSS & DELBBIDGE'S Publications. 

A Complete Minor Surgery. The Physician's Vade-mecum. 
Including a Treatise on Venereal Diseases. Just published. 
By E. C. Fkanklin, M. D., Professor of Surgery in the Uni- 
versity of Michigan. Author of "Science and Art of Sur- 
gery," etc. Illustrated with 260 wood cuts. 423 pps. Octavo. 
Price, cloth, $4.00. Sheep, $4.50. 

This work is just such a one as might be expected from the pen of one 
experienced in teaching as our veteran author, and is properly designated as 
"complete." The text is lucidly and concisely written, the therapeutics 
clear and practical, and the whole is well adapted to the uses of the general 
practitioner. This book fills a gap which has never before been met, and we 
prognosticate a large demand for it. — New York Medical Times. 

Prof. Franklin has given us a work containing some new features, and 
embracing a larger field than has heretofore been covered by manuals of 
minor surgery. The work is well illustrated, and is every way a most con- 
venient and satisfactory treatise.— Chicago Medical Times (Eclectic.) 

This is a work containing all the general practitioner of medicine should 
endeavor to assimilate on the subject of surgery. For ready references and 
emergencies this work is not surpassed. We heartily recommend the work 
to the profession. The publishers have done good work in issuing the book 
so creditably, and the profession will appreciate the large distinct type used, 
and the prominence given words so as to enable the reader to secure readily 
that which he is looking for. — Cincinnati Medical Advance. 

Dr. Charles Adams, Professor of Surgery in the Chicago Homoeopathic 
College says of this new work: I have been very much pleased in the perusal 
of Franklin's Minor Surgery, issued by your house. The book, I have no 
doubt, will prove useful to the busy practitioner, and add to the reputation 
of the learned author." 

Dr. R. N. Tooker, Professor of Diseases of Children, in the Chicago 
Homoeopathic College, in reviewing the book says : " It could not be ex- 
pected that Dr. Franklin would do otherwise than write a book that would 
be creditable both to himself and to the school of medicine to which he 
belongs. He has done more than this, for this work is a veritable and valua- 
ble 'Vade mecum' to the practitioner, and there are very few members of our 
profession who wGuld not find it a profitable companion. His instruction on 
Bandaging and the application and construction of apparatus, are full and 
unusually explicit. His chapters on Venereal Diseases are alone worth the 
price of the book, and are fully up to the times." 

With this book in possession no practitioner will need any other text 
book on Minor Surgery. It is full and complete, and any bandage, dressing 
and instrument known or used is illustrated. — Dr. Valentine in Clinical Be- 
vieio (St. Louis.) 

For Sale at all the Pharmacies, or sent free on receipt of 
price. 

GROSS & DELBRXDGE, Publishers, 

48 Madison St., CHICAGO. 



GEOGS & DELBKIDGE'S Publications. 



An Index of Comparative Therapeutics, with a pro- 
nouncing Dose-List in the genitive case,— a Homoeopathic 
Dose-List, — Tables of Differential Diagnosis, Weights and 
Measures, — Memoranda concerning Clinical Thermometry, 
Incompatibility of Medicines, Ethics, Obstetrics, Poisons, 
Anaesthetics, Urinary Examinations, Homoeopathic Pharma- 
cology and Nomenclature, etc., etc. By Samuel 0. L. Potter, 
A. M., M. D., late President of the Milwaukee Academy of 
Medicine, author of " The Logical Basis of the High Potency 
Question," "Munchausen Microscopy," etc. Second edition. 

The leading feature of this book is its comparative tabular ar- 
rangement of the therapeutics of the two great medical schools. 
Under each disease are placed in parallel columns the remedies 
recommended by the most eminent and liberal teachers in both 
branches of the profession. By a simple arrangement of the 
type used, there are shown at a glance the remedies used by both 
schools, as well as the remedies peculiar to each, for any given 
morbid condition. Over forty prominent teachers are referred to 
besides occasional references to more than thirty others. In the 
first class are Bartholow, Einger, Phillips, Piffard, Trousseau, and 
Waring of the old school ; Hempel, Hughes, Hale, Euddock and 
Jousset among modern homoeopathic authorities. 

"Dr. Potter's compilation must be the result of a large amount of pains- 
taking and accurate work, and will be appreciated. As an index it is very 
elaborate and serviceable." — New England Medical Gazette. 

"The work is really a multum in parvo ; as an index it is exhaustive, and 
very often it supplies in few words the very information that is wanted."— 
British Journal of BZomozopathy. 

"I am much pleased with your Index. It is strong and will find sale 
among old as well as new school men." — Dr. J. P. Dake, Nashville, Tenn. 

"It will furnish the busy practitioner with a summary of immense practical 
value." — Dr. H. M. Paine, Albany, N. T. 

"It will be held in high appreciation by a large class of practitioners." — 
Dr. G. P. Hart, Wyoming, 0. 

"As a work of merit it will be appreciated by the profession generally." — 
Dr. J. S. Fisher, Ada, G. 

"I like the idea very much; besides giving many valuable hints to the 
practical physician, it is very interesting from a theoretical point of view." — 
Dr. H. G. Glapp, Boston. 

For sale at the Pharmacies, or sent free on receipt of price. 
Price, in cloth, $2.00 ; in flexible morocco, tuck, $2.50. 

GROSS & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



GKOSS & DELBEIDGE'S Publications. 



Liectiires on Clinical Medicine. By M. Le De. P. Jousset, 
Physician to the Hospital Saint-Jacques, of Paris ; Professor 
of Pathology and Clinical Medicine : Editor of U Art Medical. 
Translated with copious Notes and Additions by B. Ludlam, 
M. D., Professor of the Medical and Surgical Diseases of 
Women and of Clinical Midwifery in the Hahnemann Medi- 
cal College and Hospital of Chicago. Large 8vo. of over 500 
pages, cloth, $4.50; half morocco, $5.00. 

This work is one of very great interest to the profession and to 
students, embodying, as it does, about forty years of experience 
on the part of the author, and that of nearly thirty years by the 
translator. It sets forth the best and freshest pathological views ; 
the most practical application of the homoeopathic method of 
treating disease ; and a clear and forcible bed-side analysis of the 
cases that are presented. The author discusses, from a very 
practical standpoint, the questions of Alternation, Attenuation, 
Dose and Bepetition, and of Individualization and Aggravation. 
The subjects embraced in these lectures include Asthma, Emphy- 
sema, Bheumatic Endocarditis, Articular Bheumatism, Bronchitis, 
Pneumonia, Croup, Diphtheria, Typhoid Fever, Nephritis, Albu- 
minuria, Haemoptysis, Haemorrhoids, Chronic Gastritis, Scrofulous 
Ophthalmia, Hydrarthrosis, Pelvi-Peritonitis, Vaginismus, Men- 
orrhagia, etc. 

The practitioner may here find cases analogous to puzzlers 
which occur in his own practice, and cannot fail to be benefited 
by their perusal. 

"The work presents the latest pathological data, the most practical method 
of treating disease homceopathically, and a critical analysis of each case 
related. It is eminently practical and demands the use of well-proved reme- 
dies/' — From the Hahnemannian Monthly, Philadelphia. 

It contains the very best and most reliable clinical experience in the prac- 
tice of homoeopathy of any work extant in the profession. — A. E. Small, M. 
P., in the Chicago Tribune. 

I have carefully read the work and hardly know whether I admire more, 
the plain thorough pathology and diagnosis, or the practical common sense, 
honest treatment set forth. * * The Notes of Dr. Ludlam are in keeping 
with our best American authorship.— J". P. Pake, M. P., Nashville, Tenn. 

The book is of great value to practitioners and students of medicine. — J- 
W Powling, M. P., Pean of the New York Homoeopathic Medical College. 

I have read the work with a great deal of interest and find it to be eminently 
practical, and of great value to the profession. — T. 67. Comstock, M. P., St. 
Louis, Mo. 

I have spent considerable time in examining Dr. Ludlam's translation of 
Jousset's Clinical Medicine and cannot speak too highly of it. It fills a place 
in our literature which has hitherto always been vacant — II. C. Clapp, M. P., 
Editor of the New England Medical Gazette, Boston, Mass. 

GROSS & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



GEOSS & DELBEIDGE'S Publications. 



Antiseptic Medication, or Declat's Method. — By Nicho. 
Fbancis Cooke, M. D., LL. D. Emeritus Professor of The- 
ory and Practice in the Hahnemann Medical College and 
Hospital of Chicago. 128 pp. 12 mo. cloth, 1882. Price $1.00. 
Gross & Delbridge, Chicago, Publishers. 

This is the first, and must continue to be for some time, the 
only treatise on this vitally important subject, in the English 
language. It is plain and practical. Though written only for the 
physician, it cannot fail to attract attention from the intelligent 
layman every where. Especially will it be welcome to the sufferers 
from Consumption, Cancer, Pyemia, Necrosis and all forms of 
blood-poisoning, and Malaria. 

For the matter of this volume Dr. Cooke confesses his large indebtedness to 
Dr. D£clat ; but the remarkable cures of tuberculosis, cancer, septicaemia, 
eczema, and malarial fevers recorded in the latter half of the book are strictly 
original. The only treatise on the subject in the language, it must inevitably 
fall under the eye of every intelligent physician, and the present notice may 
therefore be limited to a description of its contents. These consist of an intro- 
duction, which not more lucidly sets forth the teachings of D6clat than it ef- 
fectually demolishes the claims of his rivals, Lemaire and Lister ; some remarks 
on antiseptics in general, giving preference to phenic acid and the 
protochloride of iron prepared according to Boudreaux's method ; and an ex- 
amination of phenic acid, both in its chemical and therapeutical aspects. Be- 
sides all this, we have directions for the use of the hypodermic syringe ; and 
last, and most interesting of all to the laity, who care little how they are cured, 
full accounts of a number of cases that have been successfully treated by the 
method of Declat. The average medical man, who is more likely to close his 
ears to the voice of the sage than to the song of the siren, vill skim lightly 
over the cases of cancer, and say in his easy, superior way, that not one of them 
was a case of true cancer. He will certainly say this to his own patients, for 
whose enlightenment it may be well to mention that Dr. Cooke is an Emeritus 
Professor of Diagnosis. Dr. Cooke has been wonderfully fortunate in his use 
of the new remedy, but he has the candor to admit that he has not always 
been victorious. — TJie Chicago Tribune, Sept. 11th, 1882. 

" Antiseptic Medication " is a small volume by Dr. N. F. Cooke, of the Hahne- 
mann Medical college of this city, avowedly a treatise on the theory and method 
of Dr. De'clat, a recent visitor from the old world, which have attracted a great 
deal of attention of late. It is pretty generally safe to suspect something of 
exaggeration in almost anything which takes so sudden a hold upon popular 
enthusiasm, but it must be said, from hastily running through Dr. Cooke's ad- 
vance sheets, that he makes out a pretty strong case. * * * * 

The subject-matter treated of in Dr. Cooke's book belongs especially to the 
medical profession, and the volume can scarcely fail to be one of great interest 
to all of that profession not "hide-bound," as it is called, in foregone conclusions. 

It is clearly the work of an earnest, thoughtful, and scientific man, even 
if nothing else was known of the author. — Chicago Times, Sept. 11th, 1882. 

Sent free on receipt of price. 

GROSS & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



GEOSS & DELBKIDGE'S Publications. 

How to Feed the Sick; or, Diet in Disease. By Charles 
Gatchell, M. D. Second edition, revised and enlarged. 
12 mo. 160 pp., 1882. Price $1.00. 
This work is a very practical and timely volume not only for 
those who are sick, but also for those who are not really well, and 
to whom the problem, "What shall I eat," is of vital importance. 
As introductory, the various forms of animal, vegetable and 
inorganic foods are considered and their relative merits carefully 
pointed out. The Chapters that follow are devoted to such prac- 
tical subjects as How to feed your patients, Diet for Dyspepsia 
with aids to Digestion, Diet for Constipation, Kectal Alimenta- 
tion, etc. ; Diet in Consumption, Diet in Diabetis, Bright's 
Disease, Gravel; How to nurse the Baby, How to choose a Wet 
Nurse, How to wean the Baby, How to feed the Baby, Diet for 
Cholera Infantum, Diet for Travelers, Seasickness, the Corpulent, 
Scrofula, Kickets, Scurvy, Chlorosis, Collapse, Bheumatism, 
Asthma, Heart Disease, Alcoholism, Diarrhoea, Dysentery, Chol- 
era, Diphtheria, Gastritis, Biliousness, etc. Diet for convales- 
cents is a valuable chapter. Then follows a long and carefully 
prepared list of recipes for the preparation of Beverages, Meats, 
Broths, Soups, Breads, Gruels, etc., etc. 

Milwaukee, Wis. 
"I consider your work on "How to Feed the Sick" to be the most 
practical, and therefore the most useful, work on the subject with which I 
am acquainted. No physician should be without it; every mother should 
have it. It is in use in many of the households in which I practice." 

C. C. Olmsted, M. D. 

"This work is plain, practical and valuable. It is really a clinical guide 
on diet, and one the prof ession will find reliable and correct. " — United States 
Medical Investigator. 

"Evidently much investigation, thought and carefulness have entered 
into the production of this work, and we believe it to be worthy a place in 
every household." — Ihe Magnet. 

* * * "We have carefully examined the work and shall cheerfully 
recommend it for family use. The directions as to what food and drinks, 
and modes of preparation are very judicious." ***** 

Janesville, Wis. Resp. Yours, Dr. G. W. Chittenden & Son. 

Milwaukee, Wis., Sept. 8, 1880. 
"Prof essor Gatchell's "How to Feed the Sick" is the best book on the 
subject for the people. It contains in 160 pages an astonishing amount of 
condensed information on a subject of great importance, and one but little 
understood. Its style is admirable, pithy and to the point. The book has 
no padding about it, and deserves an immense sale." 

Sam'l Potter, M. D. 

GEOSS & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



GEOSS & DELBEIDGE'S Publications. 



1^ PRESS. 

Practitioner's Guide to Urinalysis. By Cliffoed Mitchell, 
A. D., M. D., author of "Manual of Urinary Analysis," "Clinical 
Significance of Urine," etc. 260 pages, illustrated. Price, $1.50. 

The object of this work is to teach, whether any one be greatly ex- 
perienced or not in the use of Chemicals and the Microscope. He may by its 
means learn how to analyze a specimen of urine, examine any sediment with 
the microscope, and having done so ascertain the clinical significance of such 
constituents as have been found. 

The Introduction gives more details in regard to the use of Chemicals and 
the Microscope than any book on the Urine yet published. How to use test- 
tubes, pipettes, beakers — How to heat, boil, and filter urine— How to collect 
the urine of twenty-four hours - What chemicals are necessary for an ex- 
amination of urine and how to keep them — What chemicals used stain the 
skin or clothing and how, if possible, to remove the stains — What chemicals 
used are poisonous and what their antidotes — What chemical apparatus is 
necessary, with descriptions— How to collect sediments for chemical analysis 
if desired— names of the component parts of the microscope— How to ex- 
amine sediments microscopically and to use micro-chemical re-agents— How 
to take care of and clean the microscope— Explanation of metric system 
equivalents, etc., etc. 

Part I. tells in concise language how to examine a specimen of urine 
chemically and microscopically in the shortest and simplest manner; any phy- 
sician can use the tests given intelligently and accurately. An original and 
most valuable feature of Part I. is the plan of inserting here and there a 
"Clinical Summary" explaining in concise terms the clinical significance of 
all constituents thus far demonstrated. In these "Summaries" the practioner 
will find hints to Diagnosis which, if in other works at all, are scattered through 
scores of pages. The student studying for examination will find them intoto 
an invaluable synopsis. How to detect and estimate albumin and tell if it be 
of kidney origin— How sugar, bile, the contents of deposits, as blood, pus, 
uric acid, casts, etc. may be identified with numerous cuts showing the 
microscopical appearance of the contents of sediments. The detection and 
estimation of normal constituents, as urea, sodium chloride, the phosphates, 
etc. are described and hints given with reference to calculi. 

Part II. is for the physician who is "studying up a case" and desires an 
epitome of the latest scientific knowledge on the subject, physiological, 
pathological, semiological, microscopical and chemical. Comprehensive 
lists are given of diseases and conditions in which albumin, sugar, blood, 
pus, casts, epithelia and other important constituents appear — when, the 
prognosis is favorable, when doubtful. Complete description of the urine in 
various forms of Bright's disease, in diabetes, in the oxalic acid and uric 
acid, diathesis,' etc., etc. — part played by the normal constituents, urea, 
sodium chloride, phosphates, etc. in disease. Normal urine, its quantity, 
color, odor, reaction, specific gravity, amount of solids, etc. is described and 
the Author's statistics on the daily amount collected for sixty -eight consecu- 
tive da3 7 s given. Abnormal urine is then similarly described and the effect 
of poisons on it noted. 

The more advanced student will find in part II. a chronicle of latest dis- 
coveries in urinary pathology and the latest and most improved methods of 
Qhemical and Microscopical research. 

GROSS & DELBRIDGE, Publishers, 






GEOSS & DELBKIDGE'S Publications. 



iy PHESS. 

Lectures on Fevers. By JY K. Kippax, M. D., LL. B., Prof. 

of Principles and Practice of Medicine in the Chicago 
Homoeopathic Medical College ; Clinical Lecturer and 
Visiting Physician to the Cook County Hospital ; Author 
of " Handbook of Skin Diseases," etc. Octavo 500 pp. 

The work will comprise thirty lectures, embracing every form 
of Fever; their Definition, History, Etiology, Pathology and 
Homoeopathic Treatment, making a most important and valuable 
addition to our literature. In large type and'on the best paper. 

LECTURE 1.— Fevers. Introduction. Classification of Fevers. Miasmatic, or Mala- 
rial. Miasmatic-Contagious and Contagious. The Thernometry of Fevers 

LECTURE II.— Fevers. Simple Continued Fever. — Malarial Fevers. Laws of 
Malarial, Miasmatic. Geographical Distribution, ami Incubation. 

LECTURE III.— Intermittent Fever.— Intermittent Fever Definition. Synonym. 
Historical Notice. Etiology. Clinical History. Types of Intermittent. Morbid Anatomy 
and Differential Diagnosis. 

LECTURE IV.— Intermittent Fever (continued). Complications and Sequela?. 
Prognosis Chart of Characteristics Prophylaxis. Treatment. 

LECTURE V.— Remittent Fever. Definition. Synonym. Historical Notice. Etio- 
logy. Clinical History. Morbid Anatomy. 

LECTURE VI.— Remittent Fever (continued). Differential Diagnosis. Complica- 
tions and Sequelae. Prognosis. Chart of Characteristics. Treatment. 

LECTURE VII.— Pernicious Malarial Fever.— Definition Svnonym. Historical. 
Notice. Etiology, and Clinical History Types of Pernicious Malarial Fever. Duration. 
Morbid Anatomy. Differential Diagnosis. Complications and Sequelae. ^ Prognosis. Chart 
of Characteristics. Treatment. Chronic Malarial Infection. 

LECTURE VIII.— Dengue. Definition. Synonym. Historical Survey. Etiology. 
Clinical History. Duration. Morbid Anatomy. Differential Diagnosis. Prognosis. Chart 
of Clia acteristics. Treatment. 

LECTURE IX— Hay Fever. Definition. Synonym. History and Statistics. Etiology. 
Clinical History. Differential Diagnosis. Prognosis. Prophylaxis. Treatment. 

LECTURE X.— Typho-Malarial Fever. Definition. Synonym Historical Notice. 
Etiology. Types of Typho-Malarial Fever. Clinical History. Duration. 

LECTURE XL— Tvplio-Malarial Fever (continued). Morbid Anatomy. Complica- 
tions and Sequelae. Differential Diagnosis. Prognosis. Chart of Characteristics. Treat- 
ment. 

LECTURE XII.— Miasmatic-Contagious Fevers. Typhoid Fever. Definition. 
Synonym. History and Statistics. Etiology. t 

LECTURE XIIL— Typhoid Fever (continued). Clinical History. Duration. Morbid 
Anatomy. 

LECTURE XIV.— Typhoid Fever (continued). Complications and Sequelae. Differ- 
ential Diagnosis. Prognosis. Chart of Characteristics. Treatment. 

LECTURE XV —Yeli ow Fever. Definition. Synonym. History and Statistics. 
Etiolojry. Clinical History. Differential Diagnosis. Morbid Anatomy. Complications and 
Sequelae. Prognosis. Chart of Characteristics. Treatmeut. 

The above selections from the table of contents will give the 
reader some idea of the value of this new book. The work is now 
in press and will be ready about January 1st, 1883 



GROSS & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



GBOSS & DELBEIDGE'S Publications. 

133" PRESS. 

A Compendium of Yenereal Diseases, For Practitioners and 
Students ; being a condensed description of those affections 
and their Homoeopathic Treatment. By E. C. Eeanklin, 
M. D., Professor of Surgery in the Homoeopathic Depart- 
ment of the University of Michigan; Surgeon to the 
University Homoeopathic Hospital ; Author of "Science and 
Art of Surgery," "A Complete Minor Surgery," etc., etc. 
About 112 pages. Octavo. 1883. Price $1.00. 

"This compendium of venereal diseases has been prepared by 
the author for the use of practitioners and students of medicine, 
as a summary only of the recent investigations and advance views 
touching the various sequelae that follow in the train of these con- 
tagious disorders, and to lay before the profession the knowledge 
of the present day gained by the use of comparatively small doses 
of medicine in their treatment. 

Believing in the "dualistic theory" that the origin of the 
exciting virus which produces the local contagious ulcer, differs 
from that which develops true syphilis, the terms chancroid and 
syphilis are used to designate these two essentially distinct con- 
ditions. 

It is not intended that this little treatise shall take the place 
of the larger works on venereal diseases, but that it shall be a 
useful guide and a ready reference to the general practitioner ; a 
synopsis of the more accurate and scientific observations lately 
gained in the therapeutics of these disorders. 

As such it is committed to the profession, trusting that hu- 
manity may be benefited by its teachings, and that homoeopathy 
may receive the proper credit due it in the more successful treat- 
ment of these affections by attenuated medicines, which our 
brethren of the allopathic school are slowly and grudgingly 
adopting." — Extract from Dr. Franklins Preface. 

GEOSS & DELBRIBGE, Publishers, 

48 Madison St., CHICAGO. 



GEOSS & DELBBIDGE'S Publications. 



The Physician's Condensed Account Book. An Epit- 
omized System of Book-Keeping, avoiding the necessity of 
separate Journal, Day Book and Ledger, combining system, 
accuracy and easy reference, with a minimum of labor. 272 
pages. Price, $3,50. 

The book furnishes an entirely unique system of keeping books 
for physicians. No separate Day Book, Journal or Ledger is 
required. The doctor's whole month's business is spread out 
before him on a double page, and each patron for the month has 
a line all to himself. In posting the book for the month, there is 
a column of charges against each patient treated ; another column 
in which that patient's unpaid balance of old account is brought 
forward ; another column totals due, cash paid, etc. Opposite 
each name is a column for the patient's residence, street and 
number, the year and the month. The system is simple and 
plain. 

"The book is the best I ever saw. All before your eyes. Have made 
some collections already which were forgotten, because not seen. Every 
physician should have one." Charles E. Pinkham, M D., 

Woodland, Cal. 

"Gentlemen : I have received the Physician's Condensed Account Book, 
and am very much pleased with it. I pronounce it a grand success." 

J. Deitrick, M. D., 

Petrolia, Pa. 
Gross & Delbridge, 

Gentlemen : The Account Book came to hand all right. After a trial we 
can truly say that we are very much pleased with it. It is all any medical 
man can ask in the way of book-keeping. By using every other line we are 
enabled to keep a record of our prescriptions, and we thus have a complete 
picture of our business before us. We have no hesitation in recommending 
it to the busy practitioner Yours, 

Drs. Dayfoot & McKay, 

Mt. Morris, N. Y. 
"Gross & Delbridge, 

Gentlemen : Having used the Physician's Condensed Account Book for a 
year past, I am prepared to speak intelligently as to its merits, and I truly 
regard it as the We plus ultra of book-keeping for the busy practitioner. My 
accounts are always in order. It combines accuracy with condensation." 

R. N. Tooker, M. D., 
Professor of Diseases of ( hildren, 
in the Chicago'Homceopathic College. 

The price of the Physician's Condensed Account Book is 
J53.50 net, and will be sent per express on receipt of price. 

GROSS & DELBRIDGE, Publishers, 

48 Madison St., CHfCAGO. 



GBOSS & DELBKIDGE'S Publications. 



TN PRESS. 

The American Homceopathic Dispensatory. Designed as a 
Text-Book for the Physician, Pharmacist and Student. 
About 500 pp. octavo. Illustrated. 

This important work is written in a plain and concise manner 
by a gentleman of large experience as a pharmacist, and who 
seems therefore to have fully comprehended the long felt want of 
a reliable and scientific pharmacopoeia. 

Indeed we can safely assert that this work will be to the 
Homoeopathic School what the United States Dispensatory now 
is to the Allopathic School, a desideratum. 

"The American Homoeopathic Dispensatory" 

was conceived, born and bred as a pharmaceutical text-book, and, 
as such, is intended for the druggist, the student, and the physi- 
cian. In brief, the contents are but a series of modern practical 
paragraphs, each one of which is equally important. Not in any 
one instance is there any attempt made to contort or re-arrange 
the subject matter of other Homoeopathic Pharmacopoeias, but 
the work is wholly original and replete with practical informa- 
tion. 

It is the Book for Practical Instruction. 

The volume will be an octavo of about 500 pages, printed on 
the best paper, and bound in the best manner. Be sure and buy 
no work on the subject until you have seen and examined " The 
American Homoeopathic Dispensatory." 

All orders should be addressed to 

GROSS & DEIBRIDGE, Publishers, 

48 Madison St., CHICAGO. 









1959 



